ELEMENTS  OF  PATHOLOGY. 


RINDFLEISCH. 


:PvSITY  OF  CALIFO. 
CALIFORNIA  COLLEGE  OF  ME, 
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P.  BLAKISTON,  SON  &  CO., 

No.  icia  WALNUT  STREET,  PHILADELPHIA. 


THE 

ELEMENTS  OF  PATHOLOGY: 


EDWARD   RINDFLEISCH,  M.D., 

Professor  of  Pathological  Anatomy  in  the  University  of  Wurzlnrg. 

TRANSLATED    FROM    THE    FIRST    GERMAN    EDITION, 

BY 

WM.  H.  MERCUR,  M.D.  (UNIV.  OF  PENN'A). 

R  EVI  S  E  ID 

BY 

JAMES  TYSON,  M.D., 

Professor  of  General  Pathology  and  Morbid  Anatomy  in  the  University  of  Pennsylc ania ; 
One  of  the  Physicians  to  the  Philadelphia  Hospital,  etc. 


PHILADELPHIA: 

P.    BLAKISTON,    SON   &   CO., 

No.  1012  WALNUT  STREET. 
1884. 


Entered  according  to  Act  of  Congress,  in  the  year  1884,  by 

P.  BLAKISTON,  SON  &  CO., 
In  the  Office  of  the  Librarian  of  Congress  at  Washington,  D.C. 


IN  HONOR  OF 

THE  FIFTIETH  ANNUAL  ANNIVERSARY  or  THE 
ZURICH  HIGH  SCHOOL, 

HELD 

AUGUST  2D,  1883, 
THIS   WORK    IS   RESPECTFULLY   INSCRIBED, 

IN    ORATEFt'L    REMEMBRANCE   <>F   THE    YEARS 

1861-1865, 

DURING   WHICH    I    WAS    A 

MEMBER  OF  THE   INSTITUTION. 

LONG  MAY  IT  FLOURISH,  AND  CONTINUE  TO  INSPIRE  THE 
MINDS  COMMITTED  TO  ITS  CHARGE. 


PREFACE 

TO 

THE  FIRST  GERMAN  EDITION 


This  little  work  does  not  pretend  to  be  a  text-book.  The 
author  expects,  rather,  that  the  majority  of  his  readers  are 
already  conversant  with  the  subjects  herein  treated.  Nor 
is  it  desired  to  compete  with  any  of  the  excellent  treatises 
on  this  branch  of  medicine  which  have  appeared  in  such 
gratifying  numbers  during  the  last  few  years.  His  aim  has 
been  simply  to  establish  the  natural  groundwork  which 
must  exist  in  this,  as  well  as  in  every  natural  science,  and  to 
place  it  in  as  clear  a  light  as  possible.  These  efforts  have, 
in  the  course  of  several  years,  culminated  in  this  little  book, 
which  is  now  issued  with  the  hope  of  eliciting  the  opinions  of 
his  confreres. 

EDWARD  RINDFLEISCH. 


REVISER'S  PREFACE 

TO    AMERICAN    EDITION, 


A  bigh  appreciation  of  Prof.  Rindfleisch's  work  on 
Pathological  Histology,  caused  me  to  make  careful  ex- 
amination of  these  "  Elements "  immediately  after  their 
publication  in  the  original.  From  such  an  examination 
I  became  satisfied  that  the  book  would  fill  a  niche  in  the 
wants  of  the  student,  as  well  as  of  others  who  may  desire 
to  familiarize  themselves  with  general  pathological  pro- 
cesses, viewed  from  the  most  modern  standpoint. 

I  believe  Dr.  Mercur  has  surmounted  most  of  the  well- 
recognized  difficulties  of  translation.  When  we  remember 
that  it  is  not  always  possible  to  render  into  any  language  the 
precise  meaning  of  another,  and  that  even  the  most  careful 
writers  sometimes  fail  to  make  themselves  clear  in  the  original, 
it  can  hardly  be  expected  that  a  translation  shall  be  elegant 

and  perspicuous  throughout.      Defects  of  this  kind  I  have 
xi 


xii  REVISER'S  PREFACE. 

sought  to  remove  by  carefully  reading  every  line  of  proof, 
unhampered  by  the  work  of  translating,  while  I  have  also 
compared  all  doubtful  passages  with  the  original.  But,  for 
the  above  reasons,  it  is  not  unlikely  that  defects  may  have 
escaped  attention,  for  which  we  crave  indulgence. 
Acknowledgment  is  due  to  Mr.  A.  J.  Plumer  for  making 

the  index. 

JAMES  TYSON. 

1506  SPRUCE  STREET, 
Oct.  1st,  1884. 


CONTENTS. 


PA  OH 

INTRODUCTION  AND  CLASSIFICATION 9 

GENERAL  PART. 

I.  THE  LOCAL  OUTBREAK  OF  DISEASE. 

(Protopathic  groups  of  symptoms) 13 

GENERAL  CONSIDERATIONS 14 

a.  Acute  hyperaemia 18 

b.  Congestive  hyperaemia 19 

INFLAMMATION 20 

a.  Inflammatory  irritation 20 

b.  Inflammatory  hypersemia 21 

c.  Inflammatory  exudation 22 

d.  Resolution.     1.  Arterial  hyperaemia 27 

2.   Granulation  and  cicatrization 29 

Varieties  a  nd  Termination  of  Inflammation 30 

a.  Parenchymatous ;  b.  Diphtheritic ;  c.  Catarrhal  ;  d. 
Croupous ;  e.  Ulceration  ;  f.  Inflammatory  connective-tissue 
hyperplasia ;  g.  Inflammatory  hypertrophy ;  h.  Specific  In- 
flammation   30  to  38 

FORMATION  OF  TUMORS 39 

a.  In  general 39 

b.  General  etiology  of  tumors 40 

c.  General  anatomy  and  nomenclature  of  tumors 42 

d.  Pathological  division  of  tumors 46 

e.  Benign  and  malignant  tumors 54 

II.  ANATOMICAL  EXTENSION  OF  DISEASE. 

(Deuteropathic  groups  of  symptoms) 57 

METASTASIS 58 

a.  Metastasis  through  the  lymphatics 59 

b.  Metastasis  through  the  blood 60 

Coagulation  of  the  blood  ;  thrombosis  in  the  veins  ;  thrombi 

of  the  heart  and  arteries  ;  embolism 60  to  72 

FEVER 73 

Cause  of  fever ;  fever  heat ;  disturbances  in  the  heat-regu- 
lating apparatus ;  febrile  disturbances  in  the  circulation  ; 
febrile  disturbances  in  the  organs  which  form  and  purify 

the  blood  ;  febrile  disturbances  in  the  nervous  system...  73  to  81 

Cachexia  and  Amyloid  Degeneration 82 

xiii 


xiv  CONTENTS. 

PAGE 

IRRITATION  OF  THE  NERVOUS  SYSTEM 84 

a.  General  irritation  ;  delirium  ;  coma ;  eclampsia 85 

b.  Local  irritation  ;  pain;  trismus  and  tetanus  ;  shock 87 

III.  PHYSIOLOGICAL  EXTENSION  OF  DISEASE. 

(Sympathetic  groups  of  symptoms) * 

A.    VEGETATIVE  DISTURBANCES 91 

1.  DISTURBANCES  OF  NUTRITION 92 

Necrosis ;  simple  atrophy  ;  fatty,  mucoid  and  colloid  degene- 
erations;  calcification 93  to  102 

2.  DISTURBANCES  OF  THE  CIRCULATION 101 

Local  Disturbances 102 

Arterial  ischaemia  and  collateral  circulation  ;  venous  dis- 
turbances; passive  congestion  and  oedema 102  to  106 

Hemorrhage 106 

General  Disturbances 112 

A.  Sudden  Decrease  or  Failure  in  the  Action  of  the  Heart..  114 

1.  Death  from  heart  failure 114 

2.  Collapse 116 

3.  Hypostatic  congestion  and  oedema  of  the  lungs 116 

B.  Gradual  Weakening  of  the  Heart1  s  Action 117 

1.  Compensatory  symptoms 117 

2.  Cyanosis  and  dropsy 118 

3.  DISTURBANCES  IN  THE  FORMATION  OF  BLOOD 121 

a.  Disturbances  in  the  Nutrition  supplied  by  the  Intestinal 

Tract 121 

Gastrectasis ;  vomiting  ;  diarrhoea  ;  marasmus  and  defect- 
ive nutrition 122  to  126 

b.  Disturbances  in  the  Blood  Cell  formation 127 

Essential  anaemias ;  pernicious  anaemia  ;  pseudo-leucae- 
mic  anaemia  ;  splenic  anaemia  ;  leucaemic  anaemia  ;  mela- 
naemia  and  melanosis... 128  to  131 

4.  DISTURBANCES  IN  THE  PURIFICATION  OF  THE  BLOOD 133 

a.  Disturbances  of  Respiration 134 

Dyspnoea,  or  difficult  breathing ;  gradual  suffocation ; 
Cheyne-Stoke's  respiration  ;  sudden  suffocation..  136  to  138 

b.  Disturbances  in  the  Function  of  the  Kidneys 138 

Uraemia  ;  albuminuria  and  hydrsemia  :  glycaemia  ;  dia- 
betes mellitus ;  acetonaamia ;  uric  acid  diathesis ; 
formation  of  urinary  gravel  and  calculi 138  to  147 

c.  Disturbances  in  the  Secretion  of  Bile 148 

Resorption-icterus ;   cholaemia,   haematogenous   icterus 

and  urobiluria .T 148  to  152 


CONTENTS.  XV 

B.    ANIMAL  DISTURBANCES. *152 

I.  HYPEB^ESTHESIA,  neuralgia  167 

II.  ANAESTHESIA 159 

III.  HYPERCINESIA,  CONVULSIONS 161 

Motor  neuroses  ;  epilepsy  ;  catalepsy  and  hypnotism  ; 
chorea 164  to  167 

IV.  HYPOCINESIA,  PARALYSIS 168 

a.  Peripheral  paralysis 169 

b.  Spinal  paralysis 172 

c.  Cerebral  paralysis 174 

V.  PSYCHICAL  IRRITATION  AND  PARALYSIS 175 

Moderate  psychical  irritation ;  insanity;  increased  psychi- 
cal irritation  ;  melancholia  ;  psychical  neuroses  ;  delu- 
sions ;  idiocy 176  to  178 

VI.  NEURO-VEGETAL  DISTURBANCES 179 

a.  Angio-neuroses 179 

b.  Tropho-neuroses 181 

SPECIAL  PART. 

I.  TRAUMATIC  DISEASES 187 

a.  Mechanical  trauma 187 

b.  Chemical  trauma J89 

c.  Thermic  trauma.     1.  Increase  of  temperature 192 

2.  Decrease  of  temperature 193 

3.  Diseases  of  exposure 196 

d.  Electrical  trauma 201 

II.  PARASITIC  AND  INFECTIOUS  DISEASES 201 

A.  Animal  Parasites 206 

Arthropoda;  nematodes ;  trematodes;  cestodes;  infu- 
soria    206  to  215 

B.  Vegetable  Parasites 215 

Mould  fungi ;  yeast  fungi ;  cleft  fungi 215  to  217 

III.  DEFECTIVE  DEVELOPMENT  AND  GROWTH 236 

(Preliminary  remarks) 236 

1.  Defective  arrangement  of  blastoderm 238 

(Monstrosities?) 238 

2.  Defective  intrauterine  development 241 

3.  Defective  extrauterine  development 245 

IV.  DISEASES  DVE  TO  OVERWORK 247 

V.  DISEASES  OF  INVOLUTION 250 

Conclusion ...  255 


GENERAL  PATHOLOGY. 


INTRODUCTION  AND  CLASSIFICATION. 

Disease  is  an  abnormal  condition  of  our  life  and  body, 
which  becomes  apparent  to  the  patient  himself  and  to  those 
about  him  by  variously  striking  phenomena — the  so-called 
symptoms  of  disease. 

If  we  observe  these  symptoms  attentively,  noticing  how 
they  arise,  develop  and  again  disappear,  we  soon  see  that 
they  seldom  appear  singly,  but  that  a  number  of  them  are 
generally  united,  either  at  a  certain  spot  in  the  body,  or 
around  a  strongly-marked,  so-called  cardinal  symptom.  We 
distinguish  groups  of  symptoms,  viz.:  those  of  Inflammation, 
of  Fever,  and  many  others. 

In  inflammation,  we  see  in  the  inflamed  part  redness,  pain, 
swelling,  and  increased  warmth  ;  in  fever,  the  rise  of  bodilv 
temperature  is  the  cardinal  symptom,  which  is  accompanied 
by  the  minor  symptoms  of  accelerated  pulse  and  respiration, 
chills,  loss  of  appetite,  delirium  and  increase  of  uric  acid  and 
u rates  in  the  urine. 

The  number  and  variety  of  such  groups  of  symptoms  ap- 
pear at  first  sight  very  great,  but  after  a  time  we  notice  that 
the  same  ones  reappear  in  the  most  dissimilar  diseases  ;  that, 
in  short,  typical  groups  of  symptoms  exist  which  are  funda- 
mentally connected. 

The  ordinary  course  of  diseases  is  also  somewhat  typical. 
For  almost  all  begin  with  a  local  affection,  or  produce  one 
after  a  short  time;  inflammation  sets  in  or  a  tumor  forms. 
From  this  point  local  irritation  spreads  in  two  ways : — 

First.  The  anatomical  changes  take  place,  either  by  means  of 
a  certain  continuous  process,  or  by  a  more  interrupted  advance. 
Abnormal  products  are  likely  to  form  at  the  seat  of  disease, 
spread  to  the  surrounding  parts,  be  taken  up  by  the  lymph 
and  blood  vessels,  and  thus  enter  into  the  entire  circulation 
of  the  body.  These  products  occasion  new  groups  of  syrnp- 
2  9 


10  GENERAL   PATHOLOGY. 

toms,  such  as  fever  or  metastases  of  disease  to  other  parts  of 
the  b'ody.  The  nerves  of  the  diseased  part  also  become  irri- 
tated, and  not  only  is  the  patient  made  painfully  aware  of 
their  existence,  but,  through  the  agency  of  the  central  nervous 
system,  all  kinds  of  new  symptomatic  sensations  are  produced. 
Such  are  sympathetic  affections  and  cramps,  which  at  first 
glance  seem  to  have  little  to  do  with  the  primary  affection. 

Second.  The  disturbance  of  the  function  of  the  diseased 
part  must  be  considered  as  a  means  of  spreading  the  local 
irritation.  One  for  all,  all  for  one — such  is  the  great  law 
of  the  division  of  labor,  which  governs  the  bodily  organism, 
as  absolutely  as  it  does,  or  should,  the  organism  of  the  State. 
If  now  one  part  stops  work,  the  whole  body  suffers  in  conse- 
quence. The  importance  of  the  work  of  the  diseased  part 
may  be  questioned,  but  all  work  has  a  certain  value,  and 
every  cessation  of  it  entails  suffering  upon  at  least  a  small 
number  of  adjacent  parts.  What  happens  then  when  the 
larger  vital  organs,  the  lungs,  kidneys,  heart  and  liver,  parti- 
ally interrupt,  or  imperfectly  perform  their  work?  The  blood 
current  moves  more  slowly,  the  blood  loses  its  oxygen  and 
becomes  overloaded  with  carbonic  oxide,  uric  acid  and  biliary 
products.  New  groups  of  typical  symptoms  then  arise,  such 
as  cyanosis,  dropsy,  ursemia,  jaundice  and  many  others. 

Thus  every  disease  spreads.  Even  new  local  affections 
may  in  this  way  be  generated.  But  if  this  is  not  the  case, 
and  no  vital  disturbance  of  function  has  taken  place,  the 
eventual  disappearance  of  the  primary  local  affection  also 
obliterates  its  train  of  effects,  and  the  body  reverts  gradually 
to  its  normal  condition. 

The  question  now  arises :  what  is  the  cause  of  this  typical 
uniformity,  which  shows  itself  as  well  in  the  combination  of 
individual  symptoms  into  groups,  as  in  the  succession  of  the 
latter  in  the  ordinary  course  of  disease?  This  might  readily 
be  answered  by  saying  that  these  things  exist  in  the  nature 
of  disease,  and  that  minute  investigation  shows  everywhere 
the  workings  of  cause  and  effect,  and  renders  all  such  ques- 
tioning superfluous.  Notwithstanding,  I  must  confess  that  it 
now  seems  to  me  especially  opportune  to  study  the  nature  of 
disease  in  itself,  and  thereby  to  separate  that  which  pertains 
to  the  cause  of  disease  from  that  which  is  due  to  peculiarities 
of  the  diseased  organism. 

The  present  tendency  is  to  refer  all  that  is  typical  and 


INTRODUCTION   AND   CLASSIFICATION.  11 

cyclical,  all  peculiar  local  and  actual  appearances,  to  the 
presence  of  lower  organisms,  and  thus  to  inaugurate  a  new 
ontological  era  in  Pathology.  I  desire  to  hold  myself  towards 
this  movement,  not  in  an  antagonistic,  but  in  a  conservative 
attitude,  while  endeavoring  to  separate  from  disease  as  a 
whole  that  typical  element  which  pertains  not  to  the  cause 
of  disease,  but  to  the  diseased  organism  itself. 

In  general  terms,  the  blood  and  nerves  are  the  inner  link, 
uniting  the  symptoms  into  typical  groups.  The  uniform  and 
general  presence  of  these,  and  the  similarity  of  anatomical 
and  physiological  structure,  secure  the  unity  of  our  body  and 
the  relationship  of  its  parts ;  they  determine  the  distribution 
of  bodily  diseases. 

The  foregoing  conclusions  maybe  summed  up  as  follows: — 

A  certain  number  of  groups  of  symptoms  reappear,  with 
typical  uniformity,  in  the  most  dissimilar  diseases,  because 
they  depend  upon  the  constant  factor  of  disease  in  toto,  and 
the  human  body  with  its  anatomico-physiological  structure. 
This  same  factor  also  determines  the  general  course  of  dis- 
ease. This  latter  we  may  use  as  a  framework  in  which  to 
place  the  typical  groups  of  symptoms.  In  this  way  we  gain 
a  comprehension  of  all  that  the  most  diverse  diseases  possess 
in  common,  as  well  as  a  view  of  certain  matters  usually  con- 
sidered under  the  head  of  General  Pathology,  which  I  pur- 
posely avoid  designating  as  General  Pathology,  since  it  has 
been  customary  to  include  much  under  this  head  that  belongs 
exclusively  to  Special  Pathology,  viz. :  the  study  of  parasites, 
anomalies,  etc. 

On  careful  examination,  then,  we  discover  that  most  diseases 
do  not  start  spontaneously,  but  are  the  result  of  certain  causes, 
and  it  is  the  diversity  of  these  causes  which  determines  the 
different  varieties  of  disease.  On  this  depends  the  changeful 
collectiveness  and  consecutiveness  of  symptoms,  by  which  the 
practiced  physician  distinguishes  individual  disease. 

Every  cause  of  disease  is  an  encroachment  upon  the  normal 
course  of  life.  Generally  it  is  associated  with  a  violent  and 
forced  change  in  the  physico-chemical  composition  of  a  given 
part  of  the  body.  The  disease,  as  a  whole,  represents  the 
effect  of  this  encroachment,  proceeding  partly  from  the  nature 
of  the  cause  of  disease,  and  partly  from  that  of  the  diseased 
body.  The  uniformity  of  these  results  springs,  as  we  saw,  from 
the  nature  of  the  diseased  body ;  the  absence  of  uniformity, 


12  GENERAL   PATHOLOGY. 

from  the  diversity  in  the  cause  of  disease.  The  cause  of  disease 
determines,  above  all,  the  seat  of  the  disease,  its  duration  and 
the  succession  and  combination  of  the  typical  groups  of  symp- 
toms. Those  symptoms  alone  which  are  very  unlike  can  be 
used  for  the  purpose  of  diagnosis.  I  maintain,  therefore,  that 
there  is  only  one  true,  natural  principle  of  classification  of 
disease,  one  single  point  of  observation  upon  which  a  natural 
system  of  Special  Pathology  may  be  built — namely,  the  etio- 
logical  principle  of  classification  and  the  etiological  system. 

With  this  principle  in  mind,  I  shall  endeavor  in  the  second 
or  Special  Part  of  my  work  to  group  all  diseases  accord- 
ing to  their  mode  of  origin.  We  must  then  use  the  utmost 
care  to  search  out  the  cause  of  each  individual  group,  and 
each  individual  disease,  and  describe  it — I  might  almost  say 
— as  in  natural  history ;  after  this,  to  learn  how  and  where 
it  operates  on  the  organism,  in  order  finally  to  ascertain, 
from  this  action  upon  the  organism  and  the  resulting  reaction, 
how  to  explain  the  special  picture  and  the  special  process 
peculiar  to  each  group  of  diseases  or  to  any  individual  disease. 

It  is  assuredly  not  my  intention  to  furnish  in  this  short 
work  any  comprehensive  description  of  all  these  things.  I 
beg  my  readers  to  bear  constantly  in  mind,  that  my  only  aim 
is  to  find  the  natural  foundation  of  our  common  science,  and 
to  give  to  Topographical  Pathology — which  now,  on  account 
of  its  immense  bulk,  denies  to  individuals  a  comprehensive 
view  of  the  whole — a  somewhat  higher  standpoint. 

This  Topographical  Pathology  has  been  erroneously  called 
"  Special  Pathology,"  whereas  the  "  species "  of  disease  is 
alone  determined  by  the  cause.  It  would  be  more  correct  to 
designate  it  "  Specialistic  Pathology,"  and  to  treat  it  as  a 
stepping-stone  to  "  Casuistic  or  Practical  Pathology." 


I.  THE  LOCAL  OUTBREAK  OF  DISEASE. 

PROTOPATHIC  GROUPS  OF  SYMPTOMS. 


GENERAL  CONSIDERATIONS. 

Under  the  head  of  diseased  states  presenting  protopathic 
groups  of  symptoms  we  may  consider  inflammation  and  tumor 
formation.  Both  can,  at  least,  represent  the  initial  step  of  a 
process  of  disease.  Both  are  essentially  local  disturbances. 
By  a  local  disturbance  we  understand  a  group  of  disease- 
phenomena  which  have  a  certain  part  of  the  body  for  a 
common  centre,  a  diseased  part.  The  "typical"  feature  of 
local  disturbances  arises  from  the  uniform  characters  of  the 
locality  where  they  occur.  While  it  might  appear  almost 
presumptuous,  in  view  of  the  great  diversity  of  our  organs, 
to  speak  of  a  comprehensive  uniformity  between  them,  yet 
we  may,  on  closer  examination,  readily  separate  the  varying 
from  the  permanent,  and  with  the  aid  of  the  latter  construct 
a  general  plan  of  our  bodily  organs;  in  other  words,  describe 
the  ground  upon  which  every  local  disturbance  takes  place. 
In  this  plan  the  chief  place  is  occupied  by  the  "paren- 
chyma," which  is  composed  of  or  derived  from  homogeneous 
cells,  and  is  intimately  connected  with  the  function  of  the 
organ.  Side  by  side  with  the  parenchyma  stand  the  capil- 
lary vessels  and  nerve  fibres,  which  connect  the  former  with 
the  system  at  large. 

It  was  a  bold  and  practical  idea  of  Virchow  to  trace  local 
disturbances  back  to  the  individual  cell,  hereby  freeing  path- 
ology from  the  vagueness  of  one  sided  humoral  and  neurotic 
conceptions.  But  in  attempting  to  specialize  the  field,  he 
went  a  step  too  far.  While  we  willingly  acknowledge  the  in- 
dividuality of  a  cell,  we  must  not  overlook  those  conditions 
which  restrict  its  autonomy  in  its  functional  and  nutritive 
capacity.  True,  the  cells  of  the  parenchyma  are  sensitive 
13 


14  GENERAL  PATHOLOGY. 

and  active,  but  in  this  respect  they  depend  partly  upon  the 
nervous  system ;  they  also  nourish  themselves  and  gro\v,  but 
here  again  are  partly  dependent  upon  the  blood  vessel 
system. 

The  nervous  system  controls  the  sensibility  of  the  body 
in  general.  The  non-nervous  elements  of  the  organs  have, 
for  this  reason,  by  no  means  forfeited  their  sensibility,  but 
only  yielded  a  large  share  of  the  same  to  the  central  system, 
upon  which  they,  therefore,  in  a  measure  depend.  If  they 
are  passively  excited,  a  proportionate  share  of  their  excitement 
is  immediately  communicated  through  the  sensitive  nerves  to 
the  spinal  cord  and  brain,  and  their  contractions,  if  any 
such  are  perceptible,  are  reinforced  by  the  central  nervous 
system. 

Still  more  clear  is  the  dependence  of  the  cellular  nourish- 
ment upon  the  blood  supply,  so  that  any  explanation  of  this 
point  is  needless. 

I  repeat,  therefore :  The  territory  of  the  local  disturbances  is 
made  up  of  the  three  essential  elements  named — parenchyma, 
capillaries,  and  terminal  nerves ;  but  it  is  necessary  to  add 
another,  which  occupies  a  prominent  place — connective  tissue. 
Connective  tissue,  derived  originally  from  the  mesoblast  not 
used  in  the  development  of  the  blood  vessels,  follows  the 
course  of  the  latter,  and  surrounds  them  in  their  principal 
distribution.  Moreover,  it  accommodates  itself,  in  its  histo- 
logical  changes,  to  the  peculiar  needs  of  each  in  a  wonderful 
and  perfect  manner.  In  order  to  sustain  the  connection 
between  different  parts,  it  produces  filaments  which  are  yet 
so  soft  and  flexible  as  not  to  impede  the  mobility  which 
the  function  demands.  Still  more  to  facilitate  this  mobility, 
there  are  formed,  by  fusion  of  the  basement  membrane, 
interstices,  which  are  lined  with  a  smooth,  delicate  mem- 
brane, composed  of  flattened  endothelial  cells.  To  give 
solid  form  to  an  enclosed  part,  or  a  solid  foundation  to 
superimposed  epithelium,  the  basement  membrane  hardens 
into  hyaline  membrane.  In  like  manner,  after  a  little  study, 
we  may  explain  the  origin  of  all  other  connective  tissue 
substances. 

For  our  present  purpose  we  need  only  consider  the  position 
occupied  by  the  connective  tissue  as  an  intervening  substance 
between  the  parenchyma  on  one  side  and  its  blood  and  nerve 


etween  the  parenchyma  on  one  side  and  its  b' 
ipply  on  the  other.     Physiology,  we  know, 


GENERAL   CONSIDERATIONS.  15 

about  this  intercomraunicative  office  of  the  connective  tissue. 
Pathology,  however,  is  forced  to  call  attention  to  a  number 
of  apparently  subordinate  points,  the  cognizance  of  which  is 
of  great  weight  in  the  comprehension  of  tissue  changes  in 
disease. 

In  regard  to  nourishment  by  means  of  the  blood,  it  is  im- 
portant that  the  pathologist  should  recognize  the  capillary 
membrane  as  an  endothelial  boundary  of  the  connective 
tissue.  Let  him  not  imagine  the  maintenance  of  the  paren- 
chyma- by  nutritive  material  simply  as  a  process  of  soaking 
and  rinsing,  but  rather  as  a  flow  of  sap  which  escapes  from 
the  blood  through  that  cement-substance  which  unites  the 
rhomboid  endothelial  cells  into  closed  membranes.  Outside 
of  the  capillaries  the  nutrient  fluid  runs  through  a  network 
of  juice  canals,  which  is  more  or  less  sharply  limited  by  the 
contiguous  basement  membrane  of  the  connective  tissue, 
and  contains  in  its  nodal  points  nuclei  with  protoplasmic 
threads,  called  connective  tissue  corpuscles.  Thus  the  nutri- 
tive fluid  penetrates  to  the  enveloping  membrane  of  the 
functional  parenchyma  cells,  and  remains  at  the  disposal  of 
the  latter.  Then,  loaded  with  the  products  of  the  retrograde 
metamorphosis  of  the  parenchyma  cells,  it  is  taken  up  by  the 
lymphatics,  which  are  in  intimate  union  with  the  enveloping 
membrane,  and  are  also  found  in  abundance  in  the  connective 
tissue.  In  short,  everything  that  comes  from  the  blood  passes 
by  a  somewhat  devious  course  through  the  connective  tissue, 
to  the  parenchyma  cells,  and  from  thence  into  the  lymphatic 
system.  When  I  reflect  how  many  times  I  shall  be  forced  to 
lead  my  readers  over  this  road,  and  how  the  comprehension 
of  localized  disease  is  bound  up  in  its  different  stages,  I  am 
tempted  to  call  it  the  highway  of  knowledge  of  pathological 
histology. 

As  regards  the  nerve  supply,  it  is  a  well-known  fact  that 
those  nerve  fibres  whose  office  it  is  either  to  excite  directly, 
or  to  reinforce  the  action  of  the  parenchyma,  are  in  im- 
mediate contact  with  the  parenchyma  cells,  and  form  with 
them  an  inseparable  whole.  The  same  process  takes  place 
with  the  perceptive  terminal  filaments  of  the  nerves  of  special 
sense.  The  connective  tissue,  of  course,  only  invests  and 
supports  these  nerve  fibres. 

It  is  quite  different,  however,  with  those  sensitive  nerve 
fibres  which  transmit  general  sensibility.  For  these  there 


16  GENERAL  PATHOLOGY. 

are  no  terminal  organs  with  whose  specific  energies  they 
might  be  closely  connected.  In  consequence  they  are  found 
only  in  the  connective  tissue,  where  they  divide  and  form 
networks,  which  probably  finally  unite,  without  being  sharply 
defined,  with  the  network  of  the  connective  tissue  corpuscles. 
Being  thus  merged  into  the  connective  tissue,  these  nerves 
relinquish  their  functional  uses  and  become  pre-eminently 
qualified  to  participate  in  the  general  physico-chemical 
changes  of  the  organs,  and  thus  by  corresponding  irritability 
communicate  these  changes  to  the  central  nervous  system. 
For,  together  with  the  connective  tissue,  these  nerves  come  in 
contact  with  the  innermost  structure  of  the  organs ;  with  it 
they  are  elongated  and  compressed,  and  are  subject  to  the 
same  chemical  irritations,  caused,  it  may  be,  by  a  greater 
accumulation  of  excretory  products. 

Such  irritations  are  compatible,  up  to  a  certain  point,  with 
perfect  health,  and  run  their  course  without  our  consciousness. 
Beyond  this  point  they  cause  a  vague  feeling  of  oppression, 
which  is  capable  of  a  large  number  of  peculiar  variations,  in- 
creasing perhaps  to  very  severe  boring  or  lancinating  pain.* 
These  feelings,  conscious  as  well  as  unconscious,  are  not 
without  their  effect.  The  former,  we  know,  lead  not  only 
to  discomfort  and  distress,  but  also  to  all  sorts  of  expedients 
intended  to  remedy  the  evil.  But  the  unconscious  move- 
ments are  likewise  transmitted  through  centrifugal  paths, 
and  thus  occasion  processes  which  tend  to  allay  the  local 
distress. 

What,  then,  are  these  processes  ?  First  of  all,  undoubtedly, 
the  wise  regulation  of  the  blood  supply  through  the  central 
nervous  system,  which  must  command  the  admiration  of 
every  thinking  man.  For  by  this  the  blood  always  flows  in 
increased  quantity  to  those  parts  where  the  metamorphosis  is 
heightened  by  increased  activity  (active  hypersemia),  while 
the  inactive  organs  receive,  for  the  time,  a  smaller  supply  of 
blood. 

In  what  manner  this  peculiar  reflex  is  accomplished  is  not 
yet  fully  explained.  We  know,  from  a  number  of  established 
experiments,  that  there  are  centripetal  nerve  fibres,  which, 
when  irritated,  check  the  action  of  the  vasomotor  centre 

*  Such  variations  are :  The  feeling  of  weariness,  which  is  often 
rather  pleasurable,  as  in  yawning  and  stretching :  or  of  heaviness, 
weight,  fullness,  tension,  etc. 


GENERAL   CONSIDERATIONS.  17 

and  its  branches,  depressing,  by  this  means,  the  arterial 
tonus,  and  dilating  the  arterial  lumen  (depressor  nerves). 
In  certain  vascular  localities,  whose  functions  demand  an 
exceptionally  high  degree  of  hyperaemia,  these  fibres  are 
collected  into  individual  bundles  (nervi  erigentes).  Still 
we  may  assume  that  the  sensitive  nerve  fibres  depress  the 
vasomotor  system,  and  are,  therefore,  liable  to  cause  local 
hypersemia. 

If  such  be  the  case,  we  have  before  us  one  of  the  most  in- 
genious contrivances  of  the  animal  body.  For,  taking,  first  of 
all,  active  hypersemia  into  consideration,  there  can  be  nothing 
better  adapted  to  overcome  the  pernicious  effects  of  suddenly 
increased  activity  upon  the  general  condition  of  an  organ 
than  arterial  hyperaemia.  The  chief  evil  resulting  from  an 
increased  activity  of  the  organs  is  generally  considered  to  be 
the  accumulation  of  the  so-called  products  of  tissue  metamor- 
phosis, that  is  to  say,  retrograde  chemical  products  which  re- 
duce the  excitability  of  the  parenchyma  cells.  With  the 
relaxation  of  arterial  tonus,  the  blood  pours,  as  through  an 
open  floodgate,  into  the  dilated  capillaries,  passing  so  swiftly 
through  them  that  it  has  no  time  to  give  up  its  oxygen,  and 
is  still  scarlet-red  on  reaching  the  veins.  The  products  of 
tissue  change  are,  on  the  one  hand,  more  highly  oxygenized, 
on  the  other  more  speedily  driven  out  of  the  parenchyma,  so 
that  the  exhausted  and  hungry  cells  can  thus  supply  them- 
selves with  everything  needful  for  the  restoration  of  their 
normal  shape  and  excitability. 

In  order  to  appreciate  the  full  import  of  this  reflex  action, 
we  must  turn  our  attention  once  more  to  the  general  structure 
of  our  bodily  organs.  We  now  first  perceive  that  active  hy- 
persemia includes  a  series  of  changes  whose  beginning  and  end 
are  in  the  parenchyma  cells.  These  cells  are  active  and  need 
nourishment.  In  plants  and  unicellular  animals,  activity  and 
assimilation  are  as  yet  inseparable  phases  of  the  same  process. 
In  animals,  both  are  associated  with  the  main  organs  of  the 
body,  and  are,  therefore,  capable  of  great  increase  of  activity. 
During  a  less  active  period  the  parenchyma  cells  of  higher 
animals  may  lead  a  sort  of  plant  life,  but  at  a  season  of 
heightened  activity  it  is  possible  for  them,  by  invoking  the 
aid  of  all  the  bodily  resources  (which,  we  believe,  is  effected 
by  the  connective  tissue  nerves),  to  increase  their  working 
capacity  more  and  more  until  a  point  is  reached  where  assimi- 


18  GENERAL   PATHOLOGY. 

lation  fails  to  keep  pace  with  consumption.  Thus  originates 
a  group  of  diseases,  which  our  system  will  treat  as  diseases  of 
over-exertion. 

Upon  this  series  of  changes  some  of  the  most  important  prin- 
ciples of  local  nutrition  may  be  based. 

1.  A  moderate  demand  on  the  physiological  activity  of  an 
organ,  together  with  an  abundant  supply  of  blood,  produces 
a  well  fed  condition,  which  we  will  call  Eutrophia. 

2.  Unusual,  but  gradually  heightened  activity,  and  a  cor- 
responding blood  supply  increases  the  volume  of  the  cells,  and 
also  their  number,  still  preserving  their  typical  arrangement. 
The  result  is  a  surfeited   condition,  a   Hypertrophy,  which 
appears    to    the  naked  eye  as  an  increase  of  bulk   in   the 
part. 

3.  Over-exertion,  even  in  active  hypersemia,  is,  as  already 
mentioned,  injurious.     It   leads,  among  other  things,  to  in- 
sufficient nutrition  with  a  decrease  in  bulk  of  the  parenchyma 
cells   and  the  entire  part,  called  Atrophy  of  Fatigue.     In 
all  these  things  we  see  the  dependence  of  the  assimilating 
power  upon  the  work  which  has  preceded  it.     Assimilation 
requires  vigorous  work,  though  in  moderation. 

4.  An  insufficient  demand  upon  the  physiological  activity 
leads  to  insufficient  assimilation,  and  at  the  same  time  to  that 
form  of  atrophy  called  Atrophy  of  Inaction. 

We  will  also  state  here  that  assimilation  is  an  elementary, 
if  not  the  most  elementary  property  of  the  cells,  which,  under 
conditions  hereafter  described,  may  completely  free  them- 
selves from  the  fetters  of  the  main  organism,  by  which  they 
here  seem  bound.  This  by  no  means  exhausts  the  important 
subject  of  the  regulation  of  the  blood  distribution  through  an 
excited  condition  of  the  connective  tissue  nerves.  According 
to  recognized  physiological  laws  it  is  of  no  consequence  how 
a  nerve  fibre  becomes  excited  ;  the  effect  upon  the  terminal 
organ  involved  is  governed  entirely  by  the  intensity  of  the  ex- 
citation. Consequently,  we  may  look  for  arterial  hypersemia, 
even  when  the  excitation  of  the  connective  tissue  nerves  is 
not  caused  by  nutritive  needs  of  the  peripheral  territory,  but 
by  entirely  heterogeneous  conditions,  such  as  wounds,  lux- 
ations, or  chemical  irritations  of  the  centripetal  nerves.  More- 
over, this  same  arterial  hypersemia,  which,  in  one  instance,  is 
produced  by  centripetal  irritation,  may  in  another  be  the 


GENERAL   CONSIDERATIONS.  19 

result  of  an  equivalent  action  upon  the  vasomotor  centre, 
which  action  is  derived  from  other  sources,  or  may  also  be 
caused  by  a  corresponding  disturbance  of  the  centrifugal 
vasomotor  nerve  trunks,  or  by  direct  paralysis  of  the  arterial 
tonus.  It  is  only  necessary  for  one  member  of  this  chain  of 
originally  united  conditions  to  become  prominent, — though  it 
may  be  in  an  unusual  manner, — in  order  to  bring  about 
the  pre-established  physiological  end  and  aim — arterial  hy- 
persemia. This  abnormally  produced  hypersemia  often  occurs 
in  pathology,  as  fluxion,  arterial  hypersemia  or  congestive 
hypersemia,  though  its  appearance  only  differs  in  degree  from 
that  of  physiological  hypersemia. 

The  eventual  elevation  of  the  temperature  of  the  hyper- 
semic part  deserves  to  be  especially  mentioned  among  the 
phenomena  of  congestive  hypersemia,  apart  from  the  redness 
and  swelling  already  mentioned.  This  symptom,  naturally, 
is  only  observable  in  organs  whose  normal  temperature  is  less 
than  that  of  the  blood,  because  they  are  continually  yielding 
up  large  quantities  of  heat  to  the  skin  and  contiguous 
organs.  Even  here  the  increase  of  heat  may  reach  3°  C. 
(5.4  F).  This  must  be  attributed  to  the  more  abundant 
influx  of  blood,  or  rather  to  the  increased  and  accelerated 
blood  changes  in  the  hypersemic  part. 

This  excess  of  blood,  inasmuch  as  it  runs  in  the  supplying 
arteries,  is  also  responsible  for  the  increased  tension  of  the 
arterial  walls.  This  causes  the  pulse  wave,  unchecked  by 
the  almost  exhausted  elasticity  of  the  blood-vessel  wall,  to 
communicate  brisk  pulsations  to  the  finger,  and  also  to  pass 
with  such  unusual  rapidity  through  the  artery  that  it  may 
even  penetrate  to  the  capillaries  and  veins.  The  pulsation  of 
the  arteries,  having  been  incorrectly  thought  to  denote  their 
active  participation  in  the  hypersemic  condition,  has  given 
rise  to  the  name  of  active  hypersemia.  The  microscopical 
appearances  of  congestive  hypersemia  may  be  easily  studied. 
They  consist  of  dilatation  of  the  capillaries  to  almost  twice 
their  normal  size,  and  a  rapid  flow  of  red  blood  corpuscles. 

Abundant  transudation  does  not  occur  in  pure  congestive 
hypersemia.  Pre-existing  exudates  are  diminished  rather 
than  increased  by  the  development  of  a  congestive  hyper- 


20  GENERAL   PATHOLOGY. 

INFLAMMATION. 

In  all  cases  where  a  certain  part  of  the  body  is  attacked 
by  a  cause  of  disease  in  such  a  manner  as  to  produce  marked 
alteration  in  the  blood-vessel  walls,  the  first  and  usual  result 
is  redness  and  painful  swelling ;  but  as  the  surrounding  parts, 
which  are  generally  cool,  suffer  under  these  circumstances  a 
marked  rise  of  temperature,  it  has  long  been  customary  to 
call  the  whole  group  of  symptoms  INFLAMMATION  (Phlogosis, 
Inflammatio). 

(a)  INFLAMMATORY  IRRITATION. — However  great  the  num- 
ber and  diversity  of  the  causes  of  inflammation,  one  feature  is 
common  to  all,  viz. :  the  body  itself  is  in  full  sympathy  with 
them.  An  attack  is  made — either  extraneously,  or  by  a 
poison  circulating  in  the  blood — upon  the  tissues  of  the  spot, 
which  thus  undergo  chemico-physical  changes.  How  this 
alteration  is  effected  depends  naturally  in  part  upon  the 
quality  of  the  cause  of  disease.  It  makes  a  vast  difference, 
indeed,  whether  the  tissues  are  burnt  with  sulphuric  acid, 
irritated  by  the  deposition  of  micrococci,  bruised  or  scalded. 
But  the  nature  of  the  object  of  attack  is,  on  the  other  hand, 
so  unvarying  that  the  multiplicity  of  causes  is  far  from  pro- 
ducing an  equal  multiplicity  of  effects. 

Apart  from  the  most  decided  lesion,  that  of  gangrene,  the 
metamorphosis  of  cells  and  tissues  is  about  the  same  in  every 
instance.  The  state  of  the  large  active  cells  in  the  main  bodily 
organs  will  be  considered  below.  (See  Parenchymatous  Inflam- 
mation.) There  then  remain  the  blood  vessels,  nerves,  and  con- 
nective tissue.  The  condition  of  the  fixed  connective  tissue 
cells  in  inflammation  has  been  studied,  in  connection  with 
artificial  keratitis  and  dermatitis.  These  cells  (the  con- 
nective tissue  corpuscles,  epidermic  and  lymphoid  cells)  are 
frequently  connected  with  each  other  by  offshoots.  In  this 
case  the  slightest  degree  of  inflammatory  irritation  is  marked 
by  temporary  retraction  of  the  rays  of  this  star-shaped  sub- 
stance, and  chiefly  also  by  contraction  of  the  cell  body  into  a 
roundish  lump. 

A  permanent  contraction  betokens  either  the  death  of  the 
cell,  which  manifests  itself  later  in  the  disappearance  of 
the  nucleus  and  in  granular  degeneration  of  the  cell,  or  it 
signifies  the  beginning  of  nuclear  and  cell  division,  which 
may  also  occur  without  previous  contraction  of  the  offshoots, 


INFLAMMATION.  21 

and  may,  though  somewhat  imperfectly,  contribute  to  the 
subsequent  restoration  of  the  degenerated  parts. 

In  regard  to  the  blood  vessels,  great  stress  has  of  late  been 
laid  upon  the  alteration  of  their  walls,  for  the  reason  that  this 
is  the  starting  point  of  the  most  important  stage  of  inflamma- 
tion, viz.,  exudation.  It  is,  unfortunately,  not  yet  possible  to 
give  any  comprehensive  and  satisfactory  idea  of  the  inner 
condition  of  an  inflamed  blood  vessel  wall.  Since  the  endo- 
thelia  of  the  blood  vessels  are  rightly  looked  upon  as 
the  fixed  cells  of  the  connective  tissue,  which  shut  off  the 
parenchyma  of  the  body  from  the  blood,  we  may  question 
how  far  the  changes  in  the  blood  vessel  walls  may  be 
compared  to  the  above  described  process  in  the  fixed  con- 
nective tissue  corpuscles.  There  appears,  indeed,  to  be  a 
certain  sponginess  in  the  blood  vessel  walls,  which  is  coinci- 
dent with  the  retraction  of  the  offshoots  of  the  network  of 
the  lymphoid  cells. 

Arnold  and  Thoma  have  almost  demonstrated  the  presence 
of  interstices  in  the  cement-substance  of  the  capillaries  in 
all  acute  inflammations.  Cell  division  and  increase  of  proto- 
plasm have  been  observed  in  chemical  inflammations.  But 
with  all  this  the  main  difficulty  remains  unsolved.  This  is 
the  more  to  be  regretted  as  the  alteration  of  the  blood  vessel 
walls  determines  the  future  course  of  the  inflammation. 
Its  immediate  effect  is  the  dilatation  and  engorgement  of  the 
blood  vessels  ;  in  other  words,  inflammatory  hypersemia.  To 
this  is  joined  that  escape  of  the  constituents  of  the  blood, 
known  as  inflammatory  exudation,  which  is  more  or  less 
permanent  and  especially  important  as  an  anatomical  product 
of  the  inflammatory  process. 

(6)  INFLAMMATORY  HYPERSEMIA. — In  order  to  gain  a 
correct  understanding  of  inflammatory  hypersemia,  we  shall  do 
well  to  entirely  disregard  the  current  ideas  about  arterial  and 
venous  hypersemia  and  their  origin.  The  blood  vessels  must 
be  considered,  not  as  constituents  of  the  circulatory  apparatus, 
but  as  constituents  of  the  inflamed  parenchyma.  If  it  be  true, 
as  no  one  now  doubts,  that  inflammatory  hypersemia  is  really 
produced  by  parenchymatous  changes,  it  may  safely  be  called 
parenchymatous  hypersemia.  It  appears,  aside  from  all  other 
features,  that  the  cohesion  of  the  blood  vessel  walls  is  dimin- 
ished in  inflammation.  Diminished  cohesion  is  indicated,  at 
least,  by  the  above  mentioned  yielding  of  the  blood  vessel  wall 


22  GENERAL   PATHOLOGY. 

to  the  blood  pressure,  the  dilatation  and  hypersemizatiou 
of  the  circulation. 

The  process  may  easily  be  followed  under  the  microscope  ; 
best  of  all  in  the  mesentery  of  a  living  curarized  frog,  which 
has  been  carefully  stretched  over  a  cork  ring.  In  ten  or 
fifteen  minutes  after  the  operation,  the  widening  of  the 
blood  vessels  begins.  This  reaches  its  maximum  in  one  or 
two  hours,  and  continues  so  during  the  entire  process.  Two 
hours  later  the  dilatation  is  followed  by  a  perceptible  slowing 
of  the  blood  current.  When  we  consider  that  no  obstacle  is 
offered  by  the  veins  to  the  flow  of  blood,  and  that  the  arteries 
do  not  hinder  the  blood  from  coursing,  as  in  arterial  hypenernia, 
more  swiftly  through  the  enlarged  capillaries,  we  must  regard 
this  retarded  flow  as  an  especially  characteristic  mark  of 
inflammatory  hypersemia. 

The  slowing  of  the  blood  current  can  lead  to  a  temporary 
or  even  complete  blood  stoppage  (stasis).  The  local  dilatation 
of  the  blood  vessels  is  not  a  sufficient  explanation  of  this  pro- 
ceeding. Local  dilatation  of  the  blood  vessels  also  occurs  in 
arterial  hypersemia,  which,  of  itself,  does  not  retard  the  flow 
in  a  smaller  blood  vessel.  We  must,  therefore,  revert  again 
to  the  alterations  in  the  blood  vessel  walls.  It  is  this  factor 
which  changes  the  whole  power  of  diffusibility  between  the 
blood  and  parenchyma  into  a  heightened  exosmotic  current. 
With  a  force  foreign  to  normal  nutrition,  all  the  blood  par- 
ticles are  drawn  toward  the  blood  vessel  wall,  and  thus,  among 
other  things,  the  velocity  of  their  forward  movement  is 
diminished.  I  say  "among  other  things,"  because  inflamma- 
tory exudation  is  a  far-reaching  and  important  result  of 
abnormal  exosmosis. 

(c)  INFLAMMATORY  EXUDATION. — By  inflammatory  exuda- 
tion we  understand  the  escape  of  the  constituents  of  the  blood 
from  the  blood  vessels  of  the  inflamed  tissues  and  paren- 
chyma. The  visible  result  is  either  an  infiltration  of  the 
parenchyma  with  the  escaped  material,  or  external  discharges. 

All  exudates  are  composed  of  different  constituents  of  the 
blood,  such  as  salt,  water,  albumen,  fibrinoplastic  substance, 
and  blood  corpuscles.  In  proportion  as  an  exudate  contains 
more  of  one  or  the  other  of  the  above  named  substances,  it  is 
called  serous,  fibrinous,  corpuscular  or  hemorrhagic. 

The  serous  exudate  is  closely  allied  in  composition  to  the 
normal  nutritive  juices,  except  that  the  latter,  while  nutrition 


INFLAMMATION.  23 

remains  undisturbed,  is  quickly  taken  up  by  the  parenchyma, 
which  needs  nourishment;  whereas,  the  serous  exudate  accu- 
mulates, because  the  normal  channels  of  exit  are  insufficient 
to  carry  off  an  exudate  thrown  out  with  such  rapidity  and 
abundance.  There  always  remains,  however,  the  possibility 
of  disposing  of  it  through  the  normal  channels  of  exit.  This 
generally  occurs  without  delay  as  soon  as  the  effect  of  the 
inflammatory  irritation  subsides,  so  that  the  serous  exudate 
is,  on  the  whole,  of  a  fleeting  and  temporary  character. 

Serous  exudate  is,  only  in  rare  instances,  the  culmination 
of  an  inflammation.  It  is  usually  the  forerunner  of  more 
intense  inflammation,  or  it  encircles  a  smaller  territory  where 
a  higher  degree  of  exudation  is  found,  viz.,  suppuration.  It 
is  customary  in  such  cases  to  call  it  "  inflammatory  cedema." 

Finally,  the  serous  exudate  is  found  to  be  an  important 
factor  in  inflammations  of  the  skin,  of  the  mucous,  serous 
and  other  membranes.  As  the  structure  of  these  organs  is 
unfavorable  to  an  internal  deposit  of  an  exudate,  the  serous 
discharge  seeks  the  neighboring  free  surfaces,  where  it  appears 
in  the  form  of  an  albuminous  secretion,  which  can  likewise 
act  as  a  vehicle  for  the  migratory  cells  which  exist  in  the 
parenchyma  of  the  skin. 

The  fibrinous  exudate  resembles,  in  composition,  a  sponta- 
neously coagulated,  albuminous  body,  which  bears  so  striking 
a  resemblance  to  blood  fibrin  that  we  are  tempted  to  consider 
them  as  one  and  the  same,  and  imagine  that,  in  a  fibrinous 
exudation,  the  denser  fibrinoplastic  substance  leaves  the 
blood  vessels  with  the  blood  serum,  and  afterward  hardens. 
This  hardening,  we  know,  needs  the  intervention  of  a  second 
substance  derived  from  cells.  This  is  furnished,  according  to 
Alexander  Schmidt,  by  the  colorless  blood  corpuscles.  The 
white  blood  corpuscles  which  escape  at  the  same  time  with  the 
fibrinous  exudate,  may  take  upon  themselves  the  formation  of 
this  "  fibrin  ferment."  This  is  corroborated  by  the  histological 
examination  of  the  much  feared  croupous  membrane  found  on 
the  surface  of  the  larynx  and  trachea.  Here,  the  fibrinous 
exudate  forms  a  network,  in  whose  meshes  round  cells  are 
lodged,  as  though  coagulation  had  centred  about  the  cell. 

The  exudate  itself  achieves,  by  reason  of  its  coagulation, 
a  certain  anatomical  independence.  When  seen  in  large 
quantities,  as  in  the  sero-fibrinotis  exudation  of  the  pleura, 
pericardium,  etc.,  the  fibrin  appears  to  the  naked  eye  as  a 


24  GENERAL  PATHOLOGY. 

yellowish-white,  soft,  porous  substance,  which,  upon  pressing 
out  the  moisture,  is  reduced  to  a  body  at  least  tweutyfold 
smaller,  but  tough,  thick,  and  inelastic.  It  forms  shreds  and 
flakes,  occasionally  also,  fibres,  which  entwine  themselves  in 
the  infiltrated  meshes  of  the  porous  connective  tissue,  or  are 
stretched  between  the  surfaces  of  the  serous  sacs.  The 
microscope  shows  us  here  fine  twisted  filaments,  interwoven 
into  the  most  delicate  meshes,  then,  again,  tough,  flattened 
bands,  which  form  a  network,  or  unite  into  fenestrated  mem- 
branes. These  appearances  have  given  rise  to  the  term  fibrin. 
Fibrin  also  occurs  in  the  form  of  a  granular  coagulation. 
This  appearance  in  the  blood  has  given  rise  to  much  mis- 
apprehension,* because  the  granular  bodies  are  here  seen,  in 
a  more  isolated  form,  while  in  fibrinous  exudates  they  are 
often  massed  together  in  an  indescribable  variety  of  shapes. 

It  is  self  apparent  that  the  eventual  removal  of  the  fibrinous 
exudate  is  more  complex  than  that  of  the  serous.  Even 
when  it  is  present  on  free  surfaces,  as  in  croupous  inflamma- 
tions of  the  mucous  membranes  and  lung  parenchyma,  it 
adheres  firmly,  and  a  certain  time  must  elapse  before  the  pro- 
cess of  separation  sets  in.  Still  more,  where  there  is  a  deposit 
of  fibrin  in  the  enclosed  spaces  of  the  body,  or  even  in  .the 
meshes  of  the  areolar  connective  tissue,  is  a  previous  chemical 
metamorphosis  essential  to  its  liquefaction  and  reabsorption. 
In  the  majority  of  cases,  the  fibrin  is  transformed,  along  with  a 
separation  of  fat  globules,  into  a  sodic  albuminate,  which  is 
soluble,  and  may  even  be  absorbed  through  the  walls  of  the 
blood  vessels  by  osmosis. 

It  is  a  mistaken  idea  that  fibrin  can  organize,  that  is, 
change  into  real  connective  tissue  fibres.  Whenever  connect- 
ive tissue  is  found  in  the  place  formerly  occupied  by  fibrinous 
exudate,  this  connective  tissue  has  invariably  been  produced 
from  the  corpuscular  constituents  of  the  exudate. 

Corpuscular  exudate  consists  either  entirely  of  cells,  or  to 
such  an  extent  that  the  occasional  serous  and  fibrinous  ad- 
mixture is  subordinate.  These  cells  are  originally  proto- 
plasmic masses,  destitute  of  walls,  but  containing  nuclei,  and 
having  amoeboid  motion.  They  cannot  be  distinguished  from 
the  other  mobile  cells  of  the  vascular  and  connective  tissue 
apparatus,  viz.,  the  colorless  blood  corpuscles,  lymph  corpuscles, 

*  Zirnmermann's  elementary  corpuscles,  Leidesdorf  s  syphilitic  cor- 
puscles, etc. 


INFLAMMATION.  25 

protoplasmic  cells,  etc.  Experimental  study  of  corpuscular 
exudation  has  shown  that  the  great  majority  of  these  cells 
are  either  simply  migrated  colorless  blood  corpuscles,  or 
are  derived  from  subdivision  of  the  same.  The  process  of 
escape  is  best  seen  in  the  mesentery  of  a  living  frog.  The 
individual  blood  corpuscles,  as  is  well  known,  may  be  recog- 
nized in  the  veins,  and  here  it  is  that  they  present  to  the 
observer  an  unusually  characteristic  appearance.  The  pe- 
ripheral zone  of  the  blood  current,  the  original  blood  plasma, 
becomes  filled  with  countless  colorless  blood  corpuscles,  which 
adhere  to  the  wall  and  finally  form  a  simple  and  uninter- 
rupted layer  of  globular  cells  upon  the  entire  inner  surface 
of  the  blood  vessel.  This  is  the  beginning  of  the  migratory 
process.  Small,  colorless,  button-like  elevations  arise  on  the 
outside  of  the  venous  wall,  as  if  the  blood  vessel  wall  itself 
had  produced  outgrowths.  By  slow  degrees  the  projections 
increase  in  size  till  they  lie  on  the  blood  vessel  like  hemi- 
spheres, about  half  the  size  of  white  blood  corpuscles.  The 
hemisphere  changes  gradually  into  a  pear-shaped  body,  with 
the  large  end  turned  away  from  the  blood  vessel,  and  the 
pointed  extremity  attached  to  its  wall.  The  periphery  of 
the  pear-shaped  body  now  begins  to  send  out  delicate  pro- 
longations and  ramifications,  and  the  once  smooth  surface  be- 
comes uneven  and  indented.  The  main  body  of  the  corpuscle 
recedes  more  and  more  from  the  blood  vessel  wall,  and  we  see 
finally  a  colorless,  glistening,  contractile  body,  a  wandering 
connective  tissue  cell,  which  is  nothing  more  or  less  than  a 
migrated  colorless  blood  corpuscle.  An  individual  cell  often 
occupies  more  than  two  hours  in  completing  this  process,  and 
as  the  same  phenomena  are  taking  place  simultaneously,  at 
numberless  other  points,  it  is  not  easy  to  observe  a  single  cell 
in  all  the  stages  of  the  process. 

This  active  amoeboid  movement,  this  restless  creeping  for- 
ward of  the  migrated  colorless  blood  corpuscles,  contrasts 
sharply  with  the  passive  role  which  they  enact  in  the  circu- 
lating blood.  Their  inclination  to  adhere  to  each  other  and 
to  all  stationary  points,  which  was  formerly  called  their  cohe- 
siveness,  but  is  now  recognized  as  an  outcome  of  their  anweboid 
mobility,  is,  without  doubt,  overcome  by  the  same  power 
which,  in  one  moment,  mingles  the  masses  of  blood  in  the 
heart,  and  in  the  next  scatters  it  in  a  thousand  directions. 


26  GENERAL  PATHOLOGY. 

This  mechanical  irritation  contracts  the  leucocyte  into  a  ball, 
in  which  shape  it  remains  until  a  slowing  or  partial  stop- 
page of  the  blood  current  permits  their  dormant  elasticity  to 
reassert  itself.  The  cell  division,  which  follows  closely  on  this 
cellular  migration,  must  be  regarded  as  a  further  outcome  of 
this  individual  activity.  During  the  division,  amoeboid  move- 
ment sets  in,  we  perceive  a  pellucid  band  running  transversely 
across  the  cell,  giving  the  optical  impression  of  an  annular 
constriction  of  the  surface,  which  often  vanishes  and  reappears, 
until,  at  length,  the  separation  is  suddenly  accomplished  and 
the  bisected  halves,  recoiling  from  each  other,  pursue  inde- 
pendent paths. 

Corpuscular  exudation  occurs  in  very  varying  degrees  of 
intensity.  Unimpeded  migration  and  division  lead  to  the  for- 
mation of  pus.  We  apply  the  term  pus  to  a  liquid  which 
owes  its  yellowish  color  and  thickish  consistency  to  the  sus- 
pension of  numberless  cells  in  an  otherwise  clear  and  albu- 
minous menstruum.  The  cells  of  perfectly  fresh  pus  are  equal 
in  size,  globular  in  shape,  have  sharp  outlines  and  a  whitish 
protoplasm.  The  nuclei  are  not  visible,  but  become  so  by  the 
addition  of  acetic  acid. 

Pus  appears  (1)  as  a  diffused  infiltrate;  (2)  as  a  superficial 
secretion  ;  (3)  as  an  abscess. 

The  diffused  purulent  infiltrate  shows  us  the  colorless  blood 
corpuscles  and  their  derivatives  in  the  first  stages  of  their 
journey  through  the  connective  tissue  which  envelops  the 
blood  vessels,  and  accompanies  them  in  all  their  ramifications. 
This  connective  tissue  is  succulent,  swollen,  and  yellowish- 
white  in  color,  the  latter  completely  covering  and  changing  the 
normal  coloring  of  the  inflamed  part.  The  pus  corpuscles  are 
situated  partly  in  pre-existing  connective-tissue  spaces,  in 
those  crevices  and  juice  canals  in  which  are  also  found  the 
fixed  connective  tissue  cells,  and  partly  in  the  fibrils  and 
lamellae  of  the  basement  membrane.  The  space  occupied  by 
them  here  is  only  obtainable  by  a  corresponding  melting 
away  of  the  fibrous  texture,  and  thus  it  happens  that,  in 
proportion  as  the  infiltrate  becomes  thicker  and  richer  in 
cells,  the  inflammatory  product  will  be  composed  solely  of 
cells,  which,  finally,  upon  the  addition  of  serum,  constitute  a 
pus  focus  or  abscess. 

If  the  inflamed  part  be  a  membrane,  for  instance,  a  mucous, 


INFLAMMATION.  27 

serous,  or  synovial  membrane,  the  wandering  pus  corpuscles, 
following  the  direction  of  the  least  resistance,  soon  reach  the 
surface,  where  they  appear  as  a  purulent  secretion.  This 
secretion  rarely  furnishes  pure  and  unmixed  pus,  such  as 
is  occasionally  met  with  in  purulent  inflammations  of  serous 
membranes ;  *  on  the  surface  of  synovial  membranes,  the 
exuded  pus  corpuscles  are  brought  into  contact  with  a 
large  amount  of  fluid  called  synovia,  by  means  of  which 
the  interstitial  pus  becomes  synovial  in  character;  while  in 
the  mucous  membranes  the  pus  corpuscles  mingle  with  the 
increased  mucous  secretion  and  transform  it  into  a  muco-pus. 
The  presence  of  pus,  even  in  very  trifling  quantities,  may 
always  be  detected  from  the  streaked  and  yellowish- white 
coloring  which  it  imparts  to  colorless  fluids. 

An  abscess  or  apostema  is  a  large  accumulation  of  pus, 
which  interferes  with  the  normal  continuity  of  the  bodily 
parenchyma,  as,  for  instance,  a  collection  of  pus  between  the 
muscles  in  the  skin,  brain,  glands,  etc.  Pathologically  con- 
sidered, abscesses  are  also  those  collections  of  pus  in  pre- 
existing cavities,  such  as  joints,  mucous  and  serous  sacs,  etc. 
Abscess-pus  consists  of  cells,  which,  although  already  dis- 
carded by  the  organism,  are  still  temporarily  enclosed  by  it. 
This  circumstance  may  suffice,  for  the  present,  to  explain  the 
behavior  of  the  surrounding  tissues  toward  the  abscess,  and 
especially  that  immediate  tendency  to  reject  the  pus  and  dis- 
charge it  externally  or  somewhere  along  the  course  of  the 
mucous  membrane.  To  accomplish  this  discharge,  deep  seated 
collections  of  pus  often  follow  unusual  and  roundabout 
courses,  guided  in  part  by  the  law  of  gravity  and  in  part 
following  the  direction  of  the  least  resistance.  This  latter  is 
found  in  the  strata  composed  of  loose,  areolar  connective 
tissue.  Generally  speaking,  the  pus  pursues  a  downward 
course  through  such  strata,  retaining,  however,  invariably,  the 
tendency  to  pass  from  within  outward,  and  finally  reach  the 
skin,  which  it  sooner  or  later  perforates. 

(d)  TERMINATIONS. — (a)  Secondary  Arterial  Hypercemia. — 
With  the  establishment  of  the  inflammatory  exudate  we 

*A  moment's  reflection  will  convince  us  that  a  moderate  infiltration 
of  the  membranes  in  question  must  co-exist  with  the  free  purulent 
secretion,  because  the  blood  vessels  are  everywhere  separated  from 
the  surface  by  more  or  less  dense  sheaths  of  connective  tissue,  and 
these  sheaths  must  be  traversed,  i.  e.,  infiltrated,  before  the  blood  cor- 
puscles can  appear  on  the  surface. 


28  GENERAL   PATHOLOGY. 

reach  the  point  up  to  which  the  inflammatory  cause  is 
directly  and  plainly  operative.  The  exudate,  both  in  quantity 
and  quality,  is  determined  first  of  all  by  the  nature  of  the 
inflammatory  cause.  We  may,  as  physicians,  have  done 
our  utmost  to  limit  the  quantity  of  the  discharge;  we  may 
have  tried  to  contract  the  supplying  vessels  by  persistent 
cold  applications;  we  may,  perhaps,  by  the  use  of  quinine 
and  other  "  spansemics,"  have  attempted  to  check  the  mi- 
gration of  the  colorless  blood  corpuscles ;  but  all  this  with 
very  indifferent  results.  We  still  have  before  us  an  inflam- 
matory exudate,  whose  composition  and  extent  can  only  be 
determined  approximately,  and  we  must  console  ourselves 
with  the  reflection  that  in  most  cases  the  cause  of  the  disease 
has  exhausted  itself  in  the  production  of  the  exudate,  and 
trust  to  nature  and  medical  skill  to  remove  the  exudate 
and  restore  the  normal  condition. 

In  the  matter  of  natural  healing  it  is  well  known  that 
nature  employs  no  immediate  means  of  relief.  But  should 
assimilation  be  impaired  in  any  part  of  the  organ,  should 
there  be  an  accumulation  of  substances  which  impede  the 
functions  and  render  normal  nutrition  impossible,  there 
occurs,  as  in  all  physiological  crises,  by  the  intervention  of 
the  centripetal  nerves,  an  arterial  hypersemia.  The  phe- 
nomena of  this  arterial  hypersemia  are,  of  course,  associated 
with  those  of  inflammatory  hypersemia,  but  in  character  and 
effect  this  secondary  active  hypersemia  cannot  be  too  sharply 
sundered  from  the  genuine  inflammatory  hypersemia. 

The  same  local  centre  is  common  to  both,  but  the  bounda- 
ries of  the  arterial  hypersemia  are  extended  in  proportion  as 
the  surrounding  arterial  vascular  territory  is  sympathetically 
affected.  The  characteristic  phenomena  of  arterial  hyper- 
semia, viz. :  dilatation  of  the  blood  vessels,  and  acceleration  of 
the  blood  current,  are  everywhere  apparent.  In  inflam- 
matory hypersemia  a  slowing  of  the  blood  current  takes 
place,  almost  amounting  to  stasis,  and  under  these  conditions 
the  colorless  blood  corpuscles  congregate  on  the  walls  and 
wander  out.  In  this  secondary  hypersemia,  the  blood  flows 
so  rapidly  through  the  blood  vessels,  as  not  only  to  prevent 
any  further  adhesion  of  colorless  blood  corpuscles  to  the 
walls,  but  also  to  detach  any  cells  already  there,  and,  so  to 
speak,  sweep  the  walls  clean  again.  When  this  has  taken 
place,  the  most  important  source  of  exudation  is  cut  off,  and 


INFLAMMATION.  29 

normal  circulation  is  again  restored  in  the  inflamed  part. 
The  process  of  resolution  can  now  proceed.  This  consists, 
(1)  in  relieving  the  parenchyma  from  the  exudate,  (2)  in 
restoring  the  part  to  its  former  condition. 

The  two  processes  are  entirely  distinct.  The  perfect  and 
complete  restoration  of  the  former  condition  is  only  possible 
when  the  structure  of  the  inflamed  part  has  suffered  no  injury 
from  the  exudate.  But  as  soon  as  the  structure  of  the  organ 
is,  in  the  slightest  degree,  destroyed  by  the  accumulation  of 
pus,  the  restoration  can  only  be  indirectly  and  imperfectly 
accomplished.  The  injurious  effects  of  the  cause  of  disease 
must  also  be  taken  into  account.  These  consist  very  fre- 
quently in  direct  injuries,  and  even  total  death  of  the  tissues, 
and  we  must  decide,  in  such  a  case,  whether,  and  how  far,  these 
tissues  may  be  preserved,  or  whether  they  must  be  thrown  off 
and  lost. 

(b)  Granulation  and  Cicatrization. — The  chief  measure  em- 
ployed by  the  organism  to  effect  a  definite,  even  though 
incomplete  re-establishment  of  function  is  the  formation  of 
granulation  and  scar  tissue.  This  formation  depends  upon 
the  arterial  hyperremia  in  proportion  as  the  latter  furnishes 
improved  nutrition  to  the  cells  which  form  the  blood  vessel 
wall  and  those  which  come  in  immediate  contact  with  it.  The 
dilated  capillaries  are,  accordingly,  enveloped  with  young  cells, 
which  are  only  loosely  united  together,  and  present  the  histo- 
logical  characteristics  of  young,  embryonic,  connective  tissue. 
If  they  continue  to  increase  in  such  numbers  that  the  nourish- 
ment from  the  mother  blood  vessels  becomes  insufficient,  new 
vascular  loops  form  in  a  very  simple  manner,  pushing  their 
way,  first  in  one  direction,  then  in  another,  through  the  densest 
accumulations  of  cells,  until  they  finally  empty  into  a  neigh- 
boring blood  vessel.  To  favor  their  development,  the  cells  of 
the  germinal  tissue  recede  from  each  other,  and,  simultane- 
ously, the  blood  vessel  wall  gives  way  at  those  points  where 
the  future  blood  vessels  are  to  arise,  opening  the  way  for  the 
arterial  blood  to  rush  in  and  enlarge  them.  This  phenome- 
non is  especially  well  marked  at  those  points  where  the 
smallest  terminal  arteries  merge  into  the  parenchyma  which 
they  are  to  nourish.  Hence  it  is,  that  when  it  occurs  on  a 
free  surface,  like  that  of  an  exposed  wound,  small,  soft, 
bright-red  warts  spring  up,  which  have  been  known  from  time 
immemorial  as  proud  flesh,  or  granulations. 


30  GENERAL   PATHOLOGY. 

This  connection  with  the  arterial  system  produces  in  the 
granulation  tissue  a  decided  constructive  tendency.  It  fills 
up  interstices,  smooths  over  inequalities,  and  often  replaces, 
with  astonishing  rapidity,  any  loss  of  substance.  At  the  same 
time,  the  granulations  are,  through  their  large  and  numerous 
blood  vessels,  in  intimate  relationship  with  the  bodily  organism, 
and  may  even  be  regarded  as  exceptionally  well  nourished 
parts  of  the  body.  But,  with  the  abatement  of  the  intense 
inflammatory  process,  a  change  occurs.  The  arterial  hyper- 
semia  yields,  and  the  recently  formed  tissue  becomes  metamor- 
phosed into  fibrous  connective  tissue.  The  closely  aggregated 
cells  produce  out  of  their  fused  protoplasm  a  fibrous  sub- 
stance, which  differs  from  ordinary  connective  tissue  by  the 
incomplete  terminations  of  individual  fibrils,  and  a  constant 
increase  in  thickness.  This  we  call  scar  tissue,  and  speak  of 
a  cicatricial  retraction,  or  shrinkage  of  the  original  granu- 
lation tissue.  The  blood  vessels  of  the  granulation  tissue 
suffer  in  consequence.  Many  of  them  are  obliterated,  but 
enough  remain  to  supply  the  steadily  decreasing  parenchyma 
with  sufficient  nourishment. 

SPECIAL   VARIETIES   OF   INFLAMMATION. 

The  foregoing  description  of  the  process  of  inflammation 
applies,  to  a  certain  degree,  to  all  inflammations,  but  it  suffices 
fully  only  for  local  inflammations  of  the  interstitial  con- 
nective tissue,  called  interstitial  inflammations  or  phlegmon. 
Beyond  this  the  course  of  inflammation  undergoes,  according 
to  cause  and  locality,  so  many  modifications,  that,  in  order 
to  be  explicit,  it  would  be  necessary  to  insert  at  this  point  the 
greater  portion  of  general  pathological  anatomy.  It  is  not 
my  intention  to  describe  all  known  inflammations.  I  shall, 
therefore,  limit  myself  to  some  of  the  most  important  varieties, 
which  include  a  large  number  of  minor  types. 

(a)  Parenchymatous  Inflammation. — Organs  which  consist 
mainly  of  large  parenchyma  cells,  like  the  liver,  kidneys,  and 
muscles,  often  present  peculiar  forms  of  inflammation,  which 
may  be  called  parenchymatous  inflammations.  The  chief 
symptoms  are  a  moderate  enlargement  of  the  whole  organ  ;  a 
whitish,  opaque  discoloration,  and  a  perceptible  change  into  an 
inelastic,  doughy  consistency ;  but  no  hypersemia,  or  intersti- 
tial exudation.  The  microscope  shows  that  these  changes 
result  chiefly  from  a  granular  opacity  and  swelling  of  the 


INFLAMMATION.  31 

parenchyma  cells,  while  the  blood  vessel  and  connective  tissue 
apparatus  remains  intact. 

This  "  cloudy  swelling  "  is  supposed  to  be  a  change  in  the 
cell  protoplasm,  which,  in  consequence,  looks  darker  by 
transmitted  light,  and  more  opaque  by  direct  light ;  it  also 
has  exchanged  its  normal  form  for  a  more  or  less  globular 
one.  The  cloudy  swelling  is  caused  by  a  granular  precipita- 
tion from  the  protoplasmic  juices  of  an  albuminous  body 
normally  held  in  solution.  This  precipitation  is  due,  in  turn, 
to  excessive  chemico-physical  activity,  dependent  upon  trau- 
matism.  In  mOst  cases  cloudy  swelling  may  be  compared  to  a 
cauterization  which  varies  in  depth  with  the  amount  of  caustic 
employed,  from  a  slight  and  easily  healed  irritation  to  an 
irrevocable,  escharotic  death. 

Parenchymatous  inflammation  may  be  produced  by  a  blood 
poison  attacking  the  most  susceptible  parenchyma  cells  of 
the  liver,  kidneys,  etc.  Cloudy  swelling  is  the  palpable  ex- 
pression of  a  recent  inflammatory  irritation,  and  is,  in  some 
instances,  at  least,  the  forerunner  of  a  general  process  attended 
by  hypersemia  and  exudation.  The  same  happens  in  acute 
nephritis,  and  probably  also  in  the  so  called  idiopathic  liver 
abscess  of  the  Tropics. 

Cloudy  swelling  is  generally  confined  to  low  degrees  of 
irritation,  and  as  the  granular  material  becomes  gradually 
liquefied,  the  cell  metamorphosis  ceases,  and  the  normal  con- 
dition is  restored.  This  is  strongly  corroborated  by  the  fre- 
quent discovery  of  slight  degrees  of  parenchymatous  swelling, 
and  the  whitish  discoloration  of  the  liver  and  kidneys  in  all 
infectious  and  poisonous  diseases.  On  the  other  hand,  the 
lesion  may  be  so  extensive  as  to  cause  the  cells  to  undergo  a 
fatty  and  granular  degeneration,  and  death  to  ensue  so  rapidly 
as  to  leave  no  time  for  the  development  of  an  inflammatory 
process.  This  occurs  iu  acute  yellow  atrophy  of  the  liver, 
which  will  afterward  be  discussed  at  length. 

(6)  Diphtheritic  Inflammation. — Parenchymatous  inflamma- 
tion, as  we  have  seen,  owes  its  peculiar  nature  to  certain 
peculiarities  in  the  cause  of  inflammation.  This  is  still  more 
true  of  diphtheritic  inflammation.  At  the  present  time 
diphtheritic  inflammation  is  defined  to  be  an  inflammation 
in  which  the  lodgment  of  cleft  fungi  has  produced  over  a 
greater  or  less  extent  of  surface  a  condition  of  "  coagulation 
necrosis." 


32  GENERAL   PATHOLOGY. 

Coagulation  necrosis  is  to  be  distinguished  from  the  simple 
death  of  a  part  by  the  presence  of  a  coagulated,  albuminous 
liquid,  which  accompanies  the  transition  from  life  to  death  in 
the  cells  and  tissues.  This  liquid  bears  such  a  strong  resem- 
blance to  coagulated  fibrin  that  one  is  tempted  to  consider 
them  the  same ;  except  that  the  microscopical  and  macro- 
scopical  examination  proves  that  the  coagulation  is  chiefly 
present  in  the  interior  of  the  cells,  and  in  other  constituents 
of  the  tissues. 

The  microscope  shows  a  peculiar  homogeneous  tendency  of 
the  cell  protoplasm,  accompanied  by  a  total  disappearance  of 
the  nucleus.  Thus  the  cells  lose  their  sharp  outlines,  and 
become  flaky  masses,  inclined  to  adhere  to  each  other  and  fall 
into  large,  irregular  formations  of  membranous  consistency. 
The  frequent  wax-like  appearance  of  these  coagulations  is  a 
peculiar  feature,  indicating  their  thorough  impregnation  with 
a  strong,  refractive,  albuminous  body. 

Coagulation  necrosis  appears  to  the  naked  eye  as  a  distinct 
opaque  dessication  of  the  -dead  part.  As  all  the  normal 
tissues,  not  even  excepting  the  osseous  ones,  are  of  a  partially 
transparent  consistency,  and  as  the  coagulation  necrosis  is 
generally  confined  to  a  limited  area,  we  find  sharply-defined 
patches,  which  are  distinctly  separated  from  the  surrounding 
tissues.  These,  as  already  mentioned,  somewhat  resemble 
escharotic  scabs,  and  are,  therefore,  known  as  scabs  (diph- 
theritic and  typhoid  encrustations,  etc.). 

Coagulation  necrosis  produces,  like  an  escharotic  scab,  an 
inflammatory  irritation,  which  invariably  results  in  a  process 
of  inflammation  with  corpuscular  exudate.  The  process 
varies  greatly  in  intensity.  In  a  strictly  diphtheritic  inflam- 
mation there  is  a  violent,  reactive,  inflammatory,  and  sup- 
purative  process,  which  at  best  leads  to  the  throwing  off  of 
the  coagulated  scab,  and  to  the  formation  of  deep-seated 
ulcers,  followed  by  scars.  The  diphtheritic  ulcer  can  also,  by 
repeated  recurrence  of  the  coagulations  at  the  bottom  and  at 
the  edges,  enlarge  and  deepen  to  a  considerable  extent,  and 
assume  a  gangrenous  (phagedenic)  character  before  it  begins 
to  heal  and  cicatrize. 

Using  the  term  diphtheritic  inflammation  in  a  broader 
sense,  we  may  also  include  those  analogous  occurrences 
which,  equally  with  the  diphtheritic  inflammations,  are  con- 
spicuous in  diseases  due  to  cleft  fungi.  Such  are  mainly  the 


INFLAMMATION.  33 

typhoid,  tubercular,  and  syphilitic  lesions,  and  their  accom- 
panying processes  of  inflammation  and  suppuration. 

(c)  Catarrhal  Inflammation. — The  consideration  of  catarrhal 
inflammation  should,  strictly  speaking,  be  limited  to  the 
simplest  inflammations  of  such  membranes  as  are  provided 
with  an  external  epithelium  (ectoderm  or  endoderm).  The 
slight  catarrhs  of  the  skin  and  mucous  membranes  must  not 
be  confounded  with  the  severe  purulent  inflammations  of  the 
serous  membranes  and  joints,  merely  on  account  of  a  distant 
and  purely  external  resemblance.  Catarrhal  inflammation 
presupposes  an  irritated  condition  of  the  sub-epithelial,  vas- 
cular connective  tissue.  This  may  be  induced  by  external 
irritations,  as  well  as  by  internal  ones  proceeding  from  the 
blood  or  nervous  system.  The  result  is  a  hypersemia  of  the 
connective  tissue  strata  in  question,  and  a  consequent  in- 
creased transudatory  actioji  of  the  blood  vessels. 

There  are  desquamative  catarrhs,  in  which,  the  outer 
epithelial  layer  being  stripped  off',  an  abundant  formation  and 
secretion  of  young  epithelial  cells  ensues.  There  are  also 
mucous  catarrhs  of  the  mucous  membranes  (blennorrhcea), 
and  fatty  catarrhs  of  the  skin  (seborrhoea),  in  which  the  in- 
creased glandular  secretion  is  due  to  an  over-abundaut 
nutritive  supply. 

The  small  number  of  pus  cells  found  by  the  microscope  in 
desquamative,  as  well  as  in  mucous  and  fatty  catarrhs,  points 
strongly  to  the  relation  between  them  and  true  purulent 
catarrhs.  In  a  purulent  catarrh,  numbers  of  colorless  blood 
corpuscles  escape  from  the  dilated  blood  vessels  of  the  in- 
flamed territory.  A  portion  of  them  wander  into  the  begin- 
nings of  the  lymphatics  and  local  lymphatic  glands,  which  in 
consequence  begin  to  enlarge.  A  still  larger  number  seek 
the  surface,  and  force  themselves  through  the  lowest  layer  of 
the  surface  epithelium  without  disturbing  its  integrity.  If 
the  inflamed  membrane  be  lined  with  cylindrical  epithelium, 
the  colorless  blood  corpuscles  find  easy  passage  to  the  surface, 
and,  mingling  with  the  outer  secretion,  are  discharged  with 
it.  This  is  less  easily  accomplished  in  membranes  provided 
with  stratified  pavement  epithelium.  Here  the  older  and 
more  or  less  adhesive  epithelial  strata  must  be  first  of  all 
loosened  and  thrown  off".  In  some  mucous  membranes,  par- 
ticularly those  of  the  genito-urinary  apparatus,  the  con- 
junctiva, etc.,  the  process  is  more  thorough,  and  the  catarrhal 


34  GENERAL   PATHOLOGY. 

raucous  membrane  presents  a  highly  peculiar  appearance ;  we 
see  a  red,  easily-bleeding,  spongy-porous  surface  lying  in  folds 
and  covered  with  thin  pus,  in  place  of  the  customary,  firmly- 
attached,  pale,  tender  membrane. 

Where  the  older  epithelial  layer  is  only  partially  thrown 
off,  we  see  straw-colored  vesicles  filled  with  pus  (pustules), 
which  burst,  discharge,  and  leave  a  catarrhal  erosion.  By  the 
abundant  suppuration  of  the  exposed,  bright-red,  granulating 
connective  tissue,  and  the  maceration  of  the  adjacent  epithelial 
border,  this  erosion  assumes  a  characteristic  appearance,  in- 
correctly called  ulceration. 

Such  eroded  and  purulent  spots  often  run  into  each  other, 
and  gradually  cover  large  areas,  till  they  appear  as  extensive 
as  the  purulent  catarrhal  mucous  surfaces  described  above. 
Still,  there  is  no  actual  ulceration,  and  restoration  is  consum- 
mated without  loss  of  substance  or  cicatrization. 

(d)  Croupous  Inflammation. — A  croupous  inflammation  is 
any  inflammation  having  a  fibrinous  exudate  which  is  not 
poured  out  in  the  connective  tissue,  nor  in  serous  or  other 
closed  surfaces  of  the  body,  but  which  forms  on  mucous 
membranes,  particularly  on  the  mucous  layer  of  the  respiratory 
tract.  Locally,  therefore,  it  corresponds  with  the  catarrhal 
inflammation. 

We  have  found  one  of  the  first  essentials  of  catarrhal  in- 
flammation to  be  the  presence  of  an  over  abundant  secretion 
of  the  mucous  membrane,  and  the  preservation  of  at  least  the 
lower  cylindrical-celled  layer  of  its  epithelium.  But  croupous 
inflammation,  on  the  other  hand,  is  preceded  by  a  loss  of  the 
epithelial  covering  of  the  diseased  part,.so  that  we  may  assert 
emphatically  that,  wherever  a  recent  loss  of  epithelium  is 
apparent,  the  exposed  part  suffers  from  a  fibrinous  exudation. 

This  detachment  of  the  epithelium  may  be  brought  about  by 
the  most  varied  chemico-physical  processes.  The  least  fre- 
quent is  that  of  a  mechanical  injury  or  mechanical  "  excoria- 
tion ;"  pftener  the  loss  is  caused  by  chemical  destruction  of  the 
epithelium  or  transudatory  removal  of  the  same ;  but  the  most 
frequent  agent  in  epithelial  destruction  is  unquestionably  the 
action  of  cleft  fungi  deposited  on  its  surface. 

This  is  the  case  in  the  croupous  inflammation  of  the  larynx 
and  trachea,  called  "  croup,"  which  usually  serves  as  a  para- 
digm for  this  form  of  inflammation.  The  exuding  and  rapidly- 
coagulating  fibrin  unites  with  the  cells  of  the  exudate  into  a 


INFLAMMATION.  35 

tough,  elastic,  yellowish- white  membrane,  an  exact  cast  of  the 
trachea  and  bronchi.  These  pseudo-membranes  readily  sepa- 
rate from  the  mucous  membrane,  and  may  be  coughed  up,  but 
they  adhere  with  much  more  tenacity  to  the  vocal  chords, 
which  accounts,  in  part,  for  the  great  danger  of  the  disease. 
Also  in  croupous  inflammations  of  the  lungs  this  delayed 
loosening  and  removal  of  the  exudate  is  of  serious  moment  to 
the  organism. 

The  chief  danger  of  croupous  inflammation  lies,  however, 
not  so  much  in  these  mechanical  difficulties  as  in  the  fungi, 
which,  at  the  same  time,  enter  the  blood  and  cause  severe 
fever.  The  appearance  of  fungi  establishes  the  connection 
between  croupous  and  diphtheritic  inflammation.  For  the 
same  fungus  which  destroys  the  epithelium  of  the  trachea  and 
causes  croupous  inflammation,  also  settles  upon  the  surface  of 
the  tonsils  and  produces  what  is  called  angina  tonsillaris 
(quinsy).  In  this  inflammation  we  at  first  only  find  loss  of 
epithelium  and  pseudo-membranous  exudation.  But  as  the 
tonsil  and  mucous  membranes  of  the  organs  of  deglutition  are 
not  provided,  like  the  trachea,  with  a  basement  membrane 
which  can  resist  the  attacks  of  the  cleft  fungi,  this  superficial, 
pseudo-membranous  inflammation  too  often  runs  into  a  deep- 
seated  membranous  or  diphtheritic  inflammation.  Indeed, 
since  it  is  now  well  known  that  there  are  spots  on  the  surface 
of  the  normal  tonsil  where  the  lymphatic  follicles  project,  so 
to  speak,  beyond  the  epithelium,  we  need  not  wonder  that 
numerous  depositions  of  pathogenic  organisms  occur  here, 
causing  direct  diphtheritic  inflammations  and  blood  poisoning. 

(e)  Ulceration  and  the  Ulcer. — We  have  observed  above, 
that  abscesses  can  only  be  formed  at  the  expense  of  that  con- 
nective tissue  which  serves  as  a  nidus  for  the  accumulation  of 
pus.  After  the  abscess  has  burst  and  discharged  its  pus,  there 
remains  a  "  loss  of  substance  "  (i.  e.,  cavity)  in  the  connective 
tissue,  which  is  termed  an  "  ulcer  "  as  long  as  if  remains  open, 
exposed  to  the  air,  and  without  epithelium.  The  form  of  this 
cavity  depends  upon  its  origin.  Hence,  we  distinguish  open 
and  concealed  (sinuous)  ulcers ;  ulcers  with  overhanging 
edges;  crater-like  ulcers;  ulcerous  cracks  or  rhagades,  and 
many  others.  In  considering  an  ulcer,  we  need  only  describe 
the  condition  of  its  bottom  and  edges. 

If  the  process  which  has  caused  the  ulcer  continues,  the 
bottom  becomes  covered  with  a  pus-like  layer  of  dissolved  and 


36  GENERAL    PATHOLOGY. 

disintegrated  tissues;  the  sides  appear  hard  and  infiltrated. 
If  these  substances  are  thrown  off  by  suppuration,  the  bottom 
of  the  ulcer  is  covered  with  granulations  which  fill  up  the 
gap.  Often,  indeed,  they  protrude  beyond  the  edges  (ulcusele- 
vatuni),  and  represent  an  elevation,  rather  than  a  depression. 

As  long  as  the  ununited  condition  of  the  connective  tissue 
continues,  there  is,  of  necessity,  a  secretion  of  pus,  which 
accounts  for  the  close  connection  in  the  popular  mind  between 
ulceration  and  suppuration.  The  disunion  is  encouraged,  and, 
as  it  were,  nourished,  by  the  presence  in  the  bottom  of  the 
ulcer  of  moribund  matter,  which  can  only  be  separated  by 
suppuration  from  the  organism,  and  is  so  closely  connected 
with  it  that  this  so-called  "sequestration"  is  a  process  of 
time. 

For  this  reason,  ulcers  of  the  osseous  system  readily  become 
chronic,  because  the  exposed  trabeculse  and  lamellse  in  the 
bottom  of  the  ulcer,  although  practically  dead,  are  closely 
united  with  other  deep-seated  and  living  constituents  of  the 
bone.  Tuberculous,  syphilitic,  leprous,  and  lupous  ulcers  all 
require  a  disproportionate  amount  of  time  to  throw  off  their 
deep-rooted,  specific  products  of  inflammation.  The  worst  of 
this  is,  that  as  rapidly  as  the  suppurative  process  throws  off 
these  products,  new  capita  mortua  take  their  place. 

There  are  still  other  agencies  by  which  the  ulceration  may 
be  prolonged;  chiefly,  by  a  telangiectatic  condition  of  the 
diseased  part  (phlebectasia),  the  consideration  of  which  would 
at  present  lead  too  far. 

(/)  Inflammatory  Connective  Tissue  Hyperplasia  {Chronic 
Interstitial  Inflammation).— Either  of  the  above  headings 
applies  to  the  inflammations  caused  by  an  inflammatory  irri- 
tation of  moderate  intensity,  which  is  continuous,  or  of  fre- 
quent recurrence.  The  most  frequent  mechanical  causes  are 
pressure  and  tension;  the  chemical  irritations  are  mostly 
exciting  ingredients  of  food,  such  as  alcohol,  etc.  The  action 
of  the  irritants  upon  the  tissues  does  not  immediately  threaten 
their  stability,  but  it  creates  a  want  to  which,  according  to 
known  physiological  laws,  the  organism  responds  with  a 
vigorous  and  prolonged  hypersemia.  This  latter  is  arterial  in 
character,  but  if  an  arterial  hypersemia  continues,  or  is  often 
repeated,  permanent  alterations  in  the  vascular  wall  are 
effected,  which  react,  not  alone  on  the  arterial,  but,  in  a 
heightened  degree,  on  the  venous  part  of  the  circulation. 


INFLAMMATION.  37 

The  arteries  dilate  and  lengthen,  their  walls  becoming  thicker 
by  hypertrophy  of  the  muscular  coat  and  thickening  of  the 
adventitial  connective  tissue.  The  veins,  on  the  contrary,  are, 
and  remain,  largely  dilated  ;  the  elasticity  of  their  walls  is 
exhausted,  and  therefore  it  is  not  possible  for  them  to  return 
to  their  normal  calibre.  Whether  such  a  condition  can 
be  rightly  termed  an  arterial  hypersemia  remains  an  open 
question. 

In  the  further  course  of  the  disease,  we  usually  find  newly- 
formed  connective  tissue  in  the  neighborhood  of  the  blood 
vessels.  This  resembles  granulation  tissue,  and  may  also  be 
converted  into  cicatricial  tissue.  We  may  then  expect  con- 
siderable displacement,  especially  shrinkage  of  the  organs 
involved  (cirrhosis  of  the  liver,  contraction  of  the  kidney). 
In  some  cases  the  newly  formed  connective  tissue  is  more  like 
the  normal  connective  tissue  substances,  and  occasions  thick- 
enings, depositions,  etc. ;  in  others,  the  microscope  shows  only 
a  round-celled  infiltration  of  the  connective  tissue,  especially 
that  forming  the  blood  vessel  wall,  which  does  not  lead  to 
further  changes. 

Lastly,  I  would  state  that  purely  local  thickening  of  the 
connective  tissue  without  demonstrable  hypersemia,  occurs  as 
the  result  of  slight  mechanical  disturbances  (maculae  albse  of 
the  pericardium). 

(<7)  Inflammatory  Hypertrophy. — Inflammatory  hypertrophy 
is  a  remarkable  deviation  from  the  regular  process  of  inflam- 
mation. It  shows  us  how  physiological  growth  may  lead  in 
the  latter  to  the  permanent  enlargement  of  certain  organs. 
The  elements  of  the  process  are:  hypersemia  effected  by 
pathological  irritation  and  local  increase  of  colorless  blood 
corpuscles.  However,  as  both  seem  to  concentrate  at  points 
where  the  normal  growth  of  the  involved  organs  is  taking 
place,  and  as  hypersemia  and  cell  formation  represent  in  these 
organs  the  normal  process  of  growth,  we  find  inflammation 
and  growth  to  be  identical,  and  the  result  is  an  excessive 
growth  hastened  and  increased  by  inflammatory  changes. 

Inflammatory  hypertrophy  is  most  frequently  observed  in 
the  skin  and  bones.  Active  periostitis,  which  is  important  in 
the  union  of  fractures,  as  well  as  in  other  respects,  is  an 
inflammatory  hypersemia  of  the  bone.  Elephantiasis  Ara- 
bum,  so  called,  is  another  example  of  the  same.  Although 
inflammatory  hypertrophy  resembles  active  hypertrophy  (see 


38  GENERAL  PATHOLOGY. 

p.  18),  it  is  in  reality  totally  different,  and  is  a  diseased  con- 
dition which  should  in  no  wise  be  confounded  with  the  above. 

(A)  Specific  Inflammation. — The  term  "  specific  inflamma- 
tion" must  be  applied  strictly  to  that  process  of  inflammation 
caused  by  the  lodgment  of  parasitic  bodies.  It  produces 
various  characteristic  modifications  in  the  course  and  appear- 
ance of  the  inflammation,  which  are  due  exclusively  to  its 
species  morbi.  The  consideration  of  specific  inflammations, 
i.  e.,  tubercular,  syphilitic,  leprous,  glanders,  anthrax,  etc.,  is, 
therefore,  not  in  place  here,  but  comes  properly  under  the 
head  of  parasitic  processes  of  disease,  which  form  a  separate 
division  of  special  pathology.  I  need  only  say  that  specific 
inflammations  embrace  the  most  varied  and  interesting  forms 
of  inflammation.  The  diphtheritic  form  described  above  may 
serve  as  a  paradigm  for  a  large  number.  In  this  we  have  an 
external  attack  of  cleft  fungi  and  its  consequences.  This 
attack  may  also  be  made  through  the  blood.  The  minute 
subdivided  poison  is  carried  by  the  blood  throughout  the 
whole  system.  As  the  greatest  amount  of  friction  occurs 
where  the  arteries  merge  into  the  capillaries,  it  is  here  that  the 
vascular  wall  is  most  thoroughly  inoculated  with  the  poison, 
and  the  specific  inflammation  thus  originated  is  especially 
prone  to  commence  as  endo-  and peri-arteritis.  The  corpuscular 
infiltrate  invariably  produced  shows  peculiarities  depending 
directly  upon  the  action  of  cleft  fungi.  Among  others,  there 
is  a  certain  enlargement  of  cells  with  vesicular  transfor- 
mation of  the  nuclei,  epithelioid  degeneration  culminating  in 
the  form  of  giant  cells.  Joined  to  this  are  typical  forms  of 
cell  death,  fatty  degeneration,  cloudy  swelling,  coagulation- 
necrosis  and  many  other  phases  which  strongly  influence  the 
future  course  of  the  inflammation,  and  give  it  a  characteristic 
impress. 

The  epiphytic  parasites  also  produce  peculiar  inflamma- 
tions, in  which  we  can  recognize  the  species  morbi,  each 
parasite  being  characterized  by  its  own  peculiarities  of  habit 
and  life.  The  detailed  consideration  of  this  subject  will, 
however,  be  found  in  the  Special  Part  of  this  work. 


TUMORS.  39 

TUMORS. 

(a)    GENERAL  CONSIDERATIONS. 

What  is  a  tumor?  Let  us  consider  the  question  first  at 
the  bedside  of  the  patient.  Here  we  must  face  the  difficult 
problem  whether  the  "swollen  something"  appearing  either 
upon  or  below  the  surface  of  the  body  is  an  inflammatory 
exudate  which  will  disappear  in  various  ways,  leaving  the 
part  comparatively  unimpaired,  or  whether  it  is  a  non- 
inflammatory swelling,  which,  if  left  to  itself,  will  continue  to 
grow,  and  perhaps  fatally  involve  the  rest  of  the  body. 

It  is  exceedingly  important  to  establish  the  differential  diag- 
nosis between  inflammatory  and  non-inflammatory  swellings. 
We  know  that  inflammations  generally  arise  from  distinct 
external  causes,  and  we  are,  therefore,  inclined  to  call  the 
questionable  something  a  tumor,  in  the  strict  sense  of  the 
word,  when  it  originates  spontaneously.  Inflammatory  tu- 
mors usually  develop  rapidly,  and  are  accompanied  by 
hyperaemia,  heat,  and  other  painful  sensations,  while  non- 
inflammatory tumors  develop  slowly,  from  a  minute  origin, 
are  unaccompanied  by  hypersemia  or  pain,  and  are  at  first 
only  mechanically  annoying,  although  their  inexorable  in- 
crease in  size  soon  renders  the  patient  restless  and  uneasy. 
From  these  symptoms  we  are  able,  in  doubtful  cases,  to  form 
a  temporary  diagnosis. 

We  have  noticed  before  how,  in  inflammation,  the  diseased 
organ  becomes  flooded  with  exudate.  Blood-serum,  fibrin, 
and  colorless  cells  rapidly  take  possession  of  a  certain  terri- 
tory, which  they  relinquish,  after  having  occupied  it  for  a 
certain  length  of  time,  and  disappear,  leaving  scarcely  a  trace 
behind  them.  The  diseased  organ  is  in  the  meantime  power- 
fully affected ;  but  although  it  may  be  reduced  in  size, 
changed  in  shape,  and  crippled,  from  the  effects  of  the  in- 
flammation, it  has  of  itself  contributed  nothing  to  its  own 
destruction  ;  it  has  been  destroyed. 

The  very  opposite  occurs  in  the  formation  of  tumors.  No 
conspicuous  participation  of  the  blood  and  blood  vessels  is 
here  noticed.  This  increase  of  size  is  not  derived  from  with- 
out. The  increase  is  the  product  of  the  local  cells.  These 
cells  not  only  proliferate,  but  also  change  in  character,  so 
that  when  the  part  has  lost  its  normal  shape  and  color,  when 
its  size  and  its  composition  are  changed,  and  when,  finally,  it 


40  GENERAL  PATHOLOGY. 

is  totally  destroyed,  we  can  truly  say  that  it  has  worked  out  its 
own  destruction. 

Investigating  the  nature  of  the  local  changes  still  further, 
we  encounter  everywhere  phenomena  which  have  their  natural 
models  in  the  processes  of  normal  growth.  This  is  especially 
true  of  the  elementary  histological  processes.  Cell-  and 
nuclear-division  conform  strictly  to  the  physiological  type. 
In  most  tumors,  we  find  that  complicated  form  of  cell 
division  which  is  characterized  by  the  division  of  the  nuclear 
substance  into  two  parts,  one  of  which  refracts  light  strongly, 
the  other  to  a  much  less  degree.  The  former  forms  a 
network  which  resolves  itself  into  sections;  these  sections 
then  assume  the  shape  of  an  equatorial  plate,  and  finally 
form  the  amphiaster.  Occasionally  the  new-formed  cells 
are  larger  than  normal,  and  even  attain  gigantic  growth, 
although  the  endeavor  to  retain  the  type  of  the  mother  cell  is 
always  apparent. 

This  retention  of  the  type  is  still  more  distinct  when  we 
consider,  as  we  shall  presently,  the  conversion  of  cells  into 
tissues,  and  tissues  into  tumors.  In  short,  the  first  impression 
received  in  every  stage  of  the  process  is  that  we  have  before 
us  a  caricature  of  the  process  of  normal  nutrition.  Thus  we 
may  define  a  tumor  to  be  a  localized  growth  which  has  over- 
stepped normal  limits;  in  other  words,  a  local  perverted 
excess  of  growth. 

(6)   GENERAL   ETIOLOGY   OF  TUMORS. 

When  I  stated  above  that  tumors,  in  contradistinction  to 
inflammation,  arise  from  influences  at  work  within  the  paren- 
chyma, I  did  not  intend  to  ignore  the  fact  that  our  knowledge 
of  the  causes  of  their  origin  is  extremely  imperfect,  nor  would 
I  spare  any  pains  to  investigate  this  mysterious  subject. 

The  tendency  to  continuous  apposition  by  means  of  assimi- 
lation is  innate  in  living  tissues.  We  are  forced  to  accept 
this  tendency,  which  is  shown  in  embryonic  development, 
and  pursued  until  organs  reach  their  full  growth,  as  a  pre- 
ordained plan  of  development,  apparent  even  in  the  im- 
pregnated egg,  and  in  the  local  disposition  of  its  parts.  This 
plan  of  development  selects,  according  to  time  and  space, 
certain  points  at  which  more  intense  cell  multiplication  shall 
take  place.  The  mechanical  effect  produced  by  one  growing 
part  upon  another  exerts  a  formative  influence  upon  the  ex- 


TUMORS.  41 

ternal  shape  of  tumors.  As  a  part  increases  in  size  and 
weight,  it  exerts  a  proportionate  amount  of  pressure  and 
traction  upon  its  immediate  neighborhood,  which  in  turn  yields 
or  offers  counter-pressure.  Numerous  observations  on  the 
osseous  system  have  proved  that  while  traction  and  expansion 
accelerate,  to  a  certain  degree,  the  growth  of  a  part,  pressure 
restricts  the  same.  It  is  only  after  organs  attain  their  full 
growth,  that  a  certain  equilibrium  of  all  their  parts  is  ob- 
tained, similar  to  the  equilibrium  of  the  unimpregnated  egg 
before  the  parts  were  effectually  disturbed  by  the  process  of 
impregnation. 

The  individual  character  of  the  phenomena  of  growth 
appears  the  more  marked  as  the  part  approaches  its  full 
development.  Individual  differences  are  now  strongly  marked 
when  the  part,  having  reached  its  definite  shape  and  size,  is 
subjected  to  a  general  restriction  in  the  process  of  growth, 
which  process  is  replaced  by  that  of  nutrition.  In  these  two 
respects,  I  believe  the  function  of  the  nervous  system  to  be  a 
general  supervision  over  normal  growth,  and  also  the  direction 
of  the  nutrition  of  each  individual  part.  But  we  sometimes 
perceive  that  the  prescribed  limits  are  not  preserved,  but 
overstepped  in  places,  and  we  may  ascribe  it  to  the  fact  that 
at  some  points  the  control  of  the  nervous  system  over  the 
growth  of  certain  cells  is  impaired.  That  "  local  weakness  " 
of  the  tissues,  which  has  hitherto  been  regarded  as  the  cause  of 
tumors,  is  properly  a  weakening  of  the  nervous  apparatus  of 
one  part  as  contrasted  with  the  whole. 

The  local  weakness  is,  in  many  instances,  a  transmitted  one. 
When  we  consider  that  cancer  may  attack,  successively,  grand- 
mother, mother  and  daughter,  each  in  the  same  place  (uterus, 
stomach),  and  all  perish,  also  that  all,  or  nearly  all,  members 
of  a  family  may  be  attacked  on  the  buttock  with  fibroma,  we 
are  forced  to  conclude  that  it  is  due  to  local  weakness  in  the 
development  of  an  individual,  which  has  been  transmitted 
from  mother  to  child. 

In  other  instances,  tumors  are  developed  in  places  where, 
from  infancy,  a  wart,  birth-mark,  or  some  other  blemish,  has 
betrayed  a  weak  spot  in  the  process  of  growth.  Again,  the 
organ  which  undergoes  tumor-degeneration  may  not  have 
reached  the  place  assigned  it  in  the  normal  process  of  devel- 
opment, and  may  stand,  consequently,  in  exceptional  relations 
to  the  common  organism  (testicles  retained  in  inguinal  canal). 
4 


42  GENERAL    PATHOLOGY. 

To  this  category  belong  certain  isolated  and  detached  frag- 
ments of  germinal  tissue,  in  particular,  parts  of  the  ectoderm, 
which  occasionally  appear  as  the  nuclei  of  tumors. 

Notwithstanding  all  the  evidence  in  favor  of  the  hereditary 
nature  of  tumors,  we  cannot  deny  that  the  weakness  leading 
to  the  formation  of  tumor  often  seems  an  acquired  one.  In 
the  osseous  system,  sarcomata  form  over  the  seat  of  fractures 
united  years  before.  Scars  are  often  chosen  as  the  seat  of 
sarcomatous  or  cancerous  changes.  Chronic  catarrhal  and 
hyperplastic  conditions  of  the  portio  cervicalis  uteri  are  fol- 
lowed by  cancer ;  simple  gastric  ulcers  pass  into  cancer  of  the 
stomach  ;  in  short,  wherever  a  former  inflammation  has  left  a 
tissue  minoris  vitce,  or  a  part  has  been  weakened  by  a  chronic 
inflammatory  or  ulcerative  process,  we  need  not  be  surprised 
to  find  that  arbitrary  growth,  that  wildness  in  the  processes 
of  assimilation,  which  leads  to  the  formation  of  tumors. 

a.  General  Anatomy  and  Nomenclature  of  Tumors. — Every 
abnormal  local  outgrowth  leads  to  a  circumscribed  accumula- 
tion of  new-formed  tissue,  which,  judged  by  sight  and  touch, 
is  called  a  tumor.  The  extent  and  shape  of  a  tumor  are 
determined  by  the  resistance  offered  it  by  the  surrounding 
parenchyma,  and  by  its  own  consistency  and  manner  of 
growth.  If  the  tumor  meet  with  a  uniform  resistance  from 
the  surrounding  parts,  as,  for  example,  when  one  develops  in 
the  right  hepatic  lobe,  it  is  forced  to  assume  its  most  condensed 
shape,  and  appear  as  a  sphere  or  node.  If  the  resistance  of 
one  of  the  neighboring  parts  be  disproportionately  great,  the 
tumor  becomes  flattened  upon  the  side  of  the  greatest  resist- 
ance, but  develops  spherically  in  other  directions,  thus  assum- 
ing the  shape  of  a  hemisphere.  This  is  the  case  when  a 
hepatic  tumor  develops  immediately  under  the  capsule,  and  is 
opposed,  not  so  much  by  the  capsule  as  by  the  firm,  unyielding 
wall  of  the  muscular  strata  of  the  abdominal  covering,  or  the 
diaphragm.  If,  on  the  other  hand,  the  resistance  on  one  side 
be  disproportionately  slight,  the  tumor  soon  spreads  beyond 
the  domain  of  the  affected  organ.  The  shape  now  assumed  is 
prescribed  by  its  characteristic  manner  of  growth,  in  as  far  as 
that  is  free  and  unopposed.  A  tumor  starting  in  the  papillae 
of  the  skin  is  able  to  branch  out  freely  (dendritic  vegetation), 
while  a  tumor  of  the  corium  must  first,  in  the  shape  of  a  node, 
overcome  the  uniform  resistance,  and  then,  when,  by  a  process 


TUMORS.  43 

of  regular  growth,  it  has  reached  the  outer  surface  of  the 
coriura,  it  must  continue  to  develop  in  this  direction,  being 
that  of  the  least  resistance.  The  tumor  appears  as  a  flat  tuber, 
which  either  develops  into  a  flat,  tabular  swelling  (fungus), 
or  into  a  polypoid  growth  (polypus). 

Deep-seated  nodes  are  often,  in  the  process  of  growth,  forced 
to  the  surface,  pushing  the  enveloping  skin  before  them.  This 
either  causes  them  to  be  severed  from  the  organ  which  has 
produced  them,  or  to  drag  the  organ  with  them  in  their 
growth.  If  this  surface  tendency  be  lacking  in  a  deep-seated 
tumor,  it  indicates  that  it  is  becoming  rapidly  and  more  firmly 
attached  to  the  neighboring  organs. 

All  the  macroscopic  appearances  of  a  tumor  are  embraced 
under  these  heads.  The  external  form  of  a  tumor  affects  its 
quality  only  inasmuch  as  the  plan  of  development  is  more  or 
less  apparent  in  tumors  growing  upon  free  surfaces,  from 
which  fact  certain  general  rules  may  be  gained. 

Of  greater  weight  in  the  classification  of  a  tumor  are  the 
remaining  macroscopic  criteria,  viz.,  consistency,  color  and 
texture.  They,  however,  are  determined  exclusively  by  the 
minute  composition  of  the  tumor,  which  we  will  now  proceed  to 
investigate. 

Tumors,  like  the  normal  organs  of  the  body,  are  composed 
of  blood  vessels  and  parenchyma,  of  nourishment  and  parts 
to  be  nourished. 

The  vascular  system  is  net-like,  and  provided  with  endothe- 
lium.  In  other  respects,  there  is  great  diversity  of  arrange- 
ment. There  are  narrow,  and  broad,  and  even  varicose 
capillaries ;  some  of-  the  networks  are  closely  meshed,  while 
others  are  so  wide  meshed  that  the  connections  between  the 
fine  and  sparsely  distributed  vessels  can  hardly  be  perceived 
under  low  power. 

A  special  connective-tissue  covering,  to  envelop  the  blood 
vessels  and  unite  them  with  the  insulated  parenchyma,  is  often 
entirely  lacking,  so  that  the  parenchyma  is  in  close  proximity 
to  the  eudothelial  wall,  and  only  separated  from  it  by  inter-, 
stitial  space.  On  the  other  hand,  the  sheaths  of  the  capillaries 
may  become  so  dense  that  we  have  a  coarse  mass,  composed 
chiefly  of  connective  tissue,  in  which  the  blood-vessel  lumina, 
appear  so  small  as  almost  to  be  imperceptible. 

The  quantity  of  the  blood  supply  must,  accordingly,  vary 
greatly.  Equally  variable,  of  course,  are  the  conditions  of 


44  GENERAL   PATHOLOGY. 

nutrition  and  growth  which  depend  upon  the  blood  supply. 
The  necessary  blood  vessels  are  provided,  but  it  is  clear  that 
a  one-sided  growth  of  the  insulated  parenchyma,  and  an  ab- 
normal accumulation  of  tissue  between  the  blood  vessels,  with- 
out a  corresponding  expansion  of  the  blood  paths,  must  lead 
to  a  discrepancy  between  the  demand  and  the  supply  of 
the  nutritive  fluid.  It  is  true  that  in  some  tumors  the  forma- 
tion of  blood  vessels  is  in  proportion  to  that  of  parenchyma, 
but,  in  others,  the  latter  predominates  so  strongly  that  a  com- 
pression and  obliteration  of  the  vascular  system  is  the  result. 
Retrograde  changes  are  now  apt  to  set  in  in  the  parenchyma, 
especially  fatty  and  cheesy  metamorphoses,  and  also  mucous 
softening  and  colloid  degeneration,  causing  a  "spontaneous 
though  perhaps  only  partial  retrogression"  of  the  tumor.  The 
detritus  or  the  nutritive  fluid  may  be  wholly  or  in  part  ab- 
sorbed, but  more  frequently  remains  for  a  time  unabsorbed. 
Soft  spots  are  visible  here  and  there,  and  lead  to  the  formation 
of  cysts.  If  the  tumor  is  superficial,  an  external  discharge  of 
the  dead  and  degenerated  parts  ensues,  and  the  tumor  assumes 
the  character  of  a  suppurating  abscess. 

The  process  reacts  in  various  ways  upon  the  vascular  sys- 
tem. The  obliteration  of  blood  vessels  by  the  growth  of  the 
parenchyma  has  already  been  mentioned.  If  softening  and 
discharge  occur,  the  obliterated  blood  vessels  are,  as  a  matter 
of  course,  also  destroyed,  and  their  separation  from  the  still 
active  capillaries  often  occasions  hemorrhage.  The  breaking 
of  the  tumor  and  the  discharge  of  the  degenerated  parenchyma 
relieves  the  entire  blood-vessel  apparatus  of  the  tumor,  and 
allows  the  capillaries  to  expand.  This  renewed  activity  of 
the  capillaries  may  gradually  lead  to  hyper^emia,  the  originally 
stationary  character  of  which  is  easily  converted  into  an 
active  and  inflammatory  state  by  the  action  of  the  suppurating 
decomposition  in  the  bottom  of  the  ulcer.  Quantities  of  pus, 
granulations,  blood  vessels,  and  young  connective  tissue  are 
now  produced  by  the  exposed  intermediate  nutritive  appa- 
ratus. The  bottom  of  the  ulcer  becomes  partially  overspread 
with  a  thick  covering  of  the  more  harmless  products  of  in- 
flammation. These  are,  however,  all  surface  products.  As  to 
the  deeper  parts  of  the  tumor,  the  blood-vessel  apparatus 
experiences  here  also  a  decided  relief,  though  this  is  not  likely 
to  lead  to  inflammation,  but  rather  to  improved  nutrition  and 
a  more  rapid  growth  of  the  tumor.  This  confirms  the  old 


TUMORS.  45 

theory  that  the  breaking  of  a  tumor  is  generally  the  signal  for 
a  m  )Fc>  rapid  spread  of  the  disease  on  the  surface. 

The  relation  of  the  lymph  current  to  tumors  is  still  a 
disputed  point.  In  some  tumors,  as,  for  instance,  in  car- 
cinoma of  the  stomach,  lungs,  mammae  and  skin,  in  chon- 
droma  of  the  testicle,  and  also  in  cylindroma,  it  has  been 
proved  that  the  tumor  forces  itself  into  the  local  lymphatics, 
from  whence  it  spreads  by  metastasis.  This  is,  in  all  pro- 
bability, also  true  of  all  other  tumors,  with  the  exception  of 
the  angioma.  We  may  also  suppose  this  to  be  the  manner 
in  which,  in  malignant  tumors,  injurious  matter  becomes 
mixed  with  the  blood.  Reference  will  again  be  made  to  this 
point  under  the  head  of  malignant  tumors. 

In  this  early  occupation  of  the  lymphatics  we  must  remem- 
ber, (1)  that  normal  parenchymas,  like  muscular  fibre, 
ganglion-cells,  gland-acini,  etc.,  are  enclosed  in  the  lymph 
spaces  ;  (2)  that  the  lymph  capillaries  found  in  the  continuity 
of  the  connective  tissue  are  nothing  more  than  closed  canals 
on  the  outer  surface  of  the  blood  vessel  territory,  out  of  which 
the  connective  tissue  has  grown.  (Compare  remarks  on  the 
Drstructiveness  and  Malignity  of  Tumors.) 

In  considering  the  nutrition  and  growth  of  tumors,  two 
points  must  be  borne  in  mind  ;  first,  the  accumulation  of 
nutritive  material,  which  must  necessarily  occur  in  the 
interior  of  the  tumor  from  obstruction  of  the  lymphatics  ; 
second,  the  influence  exercised  upon  the  growth  of  a  tumor 
by  the  unobstructed  condition  of  its  peripheral  lymphatics. 
Whether  the  endothelium  of  the  lymphatics  plays  an  im- 
portant part  in  the  growth  of  a  tumor  is  still  an  open  ques- 
tion. I  myself  am  convinced  of  it,  and  agree  with  Virchow, 
that  the  endothelium  of  the  blood  vessels  and  lymphatics,  as 
well  as  the  fixed  connective  tissue  cells  which  separate  them, 
are  the  most  important  oncoplasts  of  the  intermediate  nutri- 
tive apparatus.  The  chondroplasts  and  osteoplasts  are,  in 
my  opinion,  only  a  subdivision  of  this  great  group  of  cells. 

In  the  parenchyma  of  tumors,  we  meet  with  the  following 
varieties  of  tissue :  fibrous  connective  tissue,  mucous,  fatty, 
lymphatic,  cartilaginous  and  osseous  tissues;  germinal  tissue, 
round-  and  spindle-celled;  nervous  and  muscular  tissue; 
epithelium. 

Leaving  the  nutritive  apparatus  out  of  the  question,  many 
tumors  consist  entirely  of  one  variety  of  tissue,  or  at  least  of 


46  GENERAL    PATHOLOGY. 

one  predominating  variety,  so  that  there  can  be  no  question 
as  to  the  proper  classification.  Every  tumor  should  derive  its 
principal  title  from  its  predominating  tissue.  Secondary  tissue 
should  be  classed  among  the  epitheta. 

The  Greek  ending  oma  is  employed  in  the  principal  titles, 
as:  Sarcoma,  Myxoma,  Fibroma,  Cystoma,  Endothelioma, 
Lyrnphoma,  Lipoma,  Osteoma,  Chondroma,  Neuroma,  Myoma, 
Epithelioma.  In  designating  the  epitheta,  we  use,  beside 
the  Greek  ending  oides,  some  Latin  adjectives,  like  fibrous, 
cartilaginous,  etc.  In  some  few  tumors,  two  kinds  of  tissue 
are  present  in  such  equal  proportions  as  to  make  the  proper 
appellation  doubtful.  This  is  so  in  Epithelioma,  where  the 
intermediate  nutritive  apparatus  has  acquired  unusual  ac- 
tivity, and  produced  for  its  blood  vessels  such  an  accumula- 
tion of  connective  tissue  as  to  render  the  epithelial  over- 
growth less  perceptible.  Of  late,  however,  it  has  been 
customary  in  such  cases  to  attribute  the  beginning  of  growth 
to  the  epithelium,  and  name  the  tumor  accordingly. 

Finally,  we  notice  a  certain  group  of  tumors  in  which  more 
than  two  tissues  are  united,  after  the  manner  of  an  organized 
body,  so  that  we  are  led  to  compare  them  to  the  miscarried 
germ  and  development  of  a  foetus.  Virchow  has  applied  to 
these  enigmatical  formations  the  name  of  Teratoma,  thus  in- 
timating a  certain  connection  with  the  province  of  diplogenesis. 
I  would  suggest  that  the  Teratoma  be  divided  into  dermoid 
cysts  and  true  terata ;  that  the  dermoid  cysts  be  considered  as 
cystic  epithelioma,  and  the  inherited  tumors  of  the  throat 
and  coccygeal  region  be  included  among  the  terata  known  as 
foetus  in  fcetu. 

b.  Pathological  Division  of  Tumors. — That  tumors  which 
are  accessible  to  anatomical  investigation,  and  are,  in  general, 
so  constituted  that  one  particular  tissue  forms  the  bulk  of 
their  growth,  should  be  named  from  the  predominating  tissue, 
is  self-apparent.  Equally  self-apparent  is  the  fact  that  this 
does  not  constitute  a  natural  system  of  division.  The  latter 
must  be  derived  from  the  nature  of  the  part  in  question.  As 
such  an  outcome  we  recognized  degenerate  growth,  and 
must,  consequently,  base  all  further  criteria  upon  the  degree 
of  degeneration  i.  e.,  the  deviation  of  tumors  from  the  physio- 
logical plan  of  growth. 

We  observe  here  that  a  certain  number  of  tumors  represent 
merely  an  excessive  growth  of  normal  constituents, — a  quan- 


TUMORS.  47 

titative  excess  of  normal  growth,  which  we  have  previously 
noticed.  Local  irritations  of  organs  are  followed  by  active 
hypersemia,  and  inflammation  of  such  an  enduring,  but  yet 
moderate  character,  that  under  their  influence  the  process  of 
exudation  merges  into  a  process  of  increased  assimilation. 
Inflammatory  hypertrophy  may,  therefore,  be  regarded  as 
the  slightest  form  of  inflammation.  Again,  we  have  found 
simple  hypertrophy  of  muscular  organs  to  be  a  consequence  of 
increased  demands  upon  their  capacity.  On  the  other  hand, 
hyperplastic  tumors,  which  we  assign  to  the  first  group,  lack 
every  external  irritation,  every  particular  excitation  tending 
to  excess  of  growth.  Take,  for  instance,  any  spot  on  the  bony 
surface  of  a  body  where,  for  some  time,  no  disease  has  ex- 
isted. The  periosteum  or  perichondrium  are  constantly 
depositing  new  aggregations  of  their  specific  products,  which 
are  in  a  typical  manner  assimilated  by  the  nutritive  apparatus 
of  the  bone,  and  treated  as  if  they  were  authorized  outgrowths, 
tubercles,  etc.  This  condition  is  customarily  designated 
as  an  "  outgrowth  "  of  the  organ  in  question  ;  in  the  example 
cited  above,  we  would  call  it  exostosis,  ecchondrosis,  etc. 

Let  us  now  contrast  heteroplastic  with  hyperplastic  tumors. 
In  the  former,  the  normal  law  of  growth  is  still  more  obscure. 
We  find  a  tissue  which  rightfully  belongs  here — though  in  a 
quantity,  time  and  arrangement  disproportionate  to  the  physio- 
logical capacity  of  the  organ — in  such  large  quantities  that  it 
seems  no  longer  a  simple  outgrowth,  but  a  foreign  structure, 
which,  having  implanted  itself  in  a  growing  organ,  clings 
to  it,  invades  it,  and  impairs  its  normal  activity.  Although 
nothing  remains  of  the  original  structure,  we  are  continually 
reminded  of  it  by  the  histological  character  of  the  new  growth, 
in  which  certain  "  characteristics  of  the  parent  tissue"  repro- 
duce themselves.  The  tenacity  with  which  the  latter  are 
manifested  throughout  the  whole  disease  is  remarkable.  We 
should  also  bear  in  mind  that,  in  spite  of  the  multiplicity  of 
heteroplastic  tumors,  the  same  parent  tissue  can  only  produce 
a  limited  quantity  of  its  kind,  and  that  each  part  of  the  body 
possesses  its  own  oncology;  the  latter  fact  affords  a  natural 
clue  to  the  special  consideration  of  the  same.  From  all  of 
which  we  conclude  that  the  growth  under  consideration, 
although  defective,  is  still  but  a  caricature  of  normal  physio- 
logical growth. 

The  number  and  variety  of  heteroplastic  tumors   is  very 


48  GENERAL    PATHOLOGY. 

great.  Accepting  the  embryonic  principle  of  development  as 
a  standard  of  division,  these  tumors  separate  readily  into  two 
large  groups. 

The  theory  of  His  concerning  the  double  nature  of  germinal 
tissue  is  constantly  gaining  ground  among  recent  investigators 
of  the  history  of  development.  His  distinguishes  (1)  Archi- 
blastic  tissues,  to  which  belong,  besides  the  epithelial  layers 
and  investments  of  the  ecto-  and  endo-derm,  the  nervous  and 
muscular  structures,  which  latter  are  usually  associated  with 
the  mesoderm  ;  (2)  Parablastic  tissues,  i.  e.,  products  of  the 
vascular  peripheral  matrix,  the  area  opaca  (germinal  disk, 
white  yolk)  of  the  embryo,  which  has  penetrated  into  the 
archiplastic  province,  and  serves  to  unite  and  nourish  the 
same.  All  connective-tissue  substances,  free  or  fixed,  belong 
to  this  class;  also  all  blood  vessels  and  the  parenchyma 
forming  the  same. 

Pursuing  this  theory,  we  divide  tumors  into  two  great 
groups — a  division  which  is  both  useful  and  natural. 

The  First  Group  contains  tumors  which  are  the  exclusive 
product  of  the  intermediate  apparatus  of  nutrition,  that  is  of 
the  former  parablast.  They  are  associated  at  their  origin  with 
the  blood  apparatus,  and  begin  by  establishing  in  the  peri- 
vascular  spaces  an  embryonic  germinal  tissue  rich  in  cells. 
From  these,  following  exactly  the  laws  of  physiological 
growth,  all  higher  tissue  types  of  the  parablastic  order  may  be 
developed,  being  more  or  less  influenced  by  the  locality  where 
they  appear.  In  this  way  arise,  Lipoma,  Fibroma,  Myxoma, 
Enchondroma,  Endothelioma,  Angioma,  etc. 

In  a  large  number  of  cases  regular  tissue  is  not  produced. 
The  new  formation  contents  itself  with  the  production  of 
those  unripe  connective-l^sue  forms,  referred  to  above  as 
occurring  in  the  inflammatory  new -growth  of  the  round  and 
spindle-celled  connective  tissue,  which  we  will  call  here  Sarco- 
matous  tissue. 

This  defective  development  of  tissue  furnishes  a  new  criterion 
for  the  degree  of  degeneration  and  the  intensity  of  the  over- 
growth, for  the  excess  of  production  is  in  inverse  ratio  to  the 
development  of  the  tissue.  The  unrestrained  constructive 
activity  occupies  itself  solely  in  completing  and  heaping  up  an 
overpowering  mass  of  cells,  whereby  the  diseased  organ  is 
destroyed,  and  the  whole  body  involved.  This  feverish  activity 
allows  little  scope  for  the  development  of  individual  cells. 


TUMORS.  49 

But  it  is  interesting  to  note,  as  before  mentioned,  how 
tenaciously  even  the  most  luxuriant  sarcomata  retain  certain 
characteristics  of  the  locality  whence  they  sprang  (ossification, 
pigmentation,  etc.) 

The  Second  Group  embraces  epithelial  tumors.  Ecto-  and 
endo-derm,  either  alone  or  in  the  customary  connection  with 
the  paraplasts,  form  the  essential  body  of  the  tumor.  Large 
numbers  of  young  epithelial  cells  are  produced,  which  only 
exceptionally  attain  a  higher  development,  but  resemble  the 
epithelial  cells  normally  occupying  their  place.  These  form 
the  subdivision  of  the  Adenoma. 

True  Carcinoma  occurs  much  more  frequently.  Here  the 
atypical  epithelial  multiplication  seems  to  have  undertaken 
the  task  of  producing  and  heaping  up,  in  as  short  a  time  as 
possible,  the  greatest  possible  number  of  young  cells.  The 
most  luxuriously  proliferating  cancers  and  sarcomata  are 
united  by  this  common  trait  into  the  clinical  group  of 
Medullary  Tumors. 

We  are  thus  enabled  to  present  the  following  summary  of 
tumors : — 

/.  Hyperplastic  Tumors. 

They  occur  chiefly  in  the  osseous  system,  in  the  skin,  and 
in  the  glands. 

Ecchondrosis. — The  most  important  are  the  cartilaginous 
outgrowths  of  the  synchond roses,  of  the  symphyses  of  the 
pelvis,  and  of  the  synchondrosis  Clivi  (Blumenbachii). 

Exostosis. — A  hard,  extensive,  bony  tumor  of  the  bones 
of  the  face  and  of  the  base  of  the  skull,  in  addition  to 
the  harmless,  button-shaped  exostosis  occurring  on  the 
vertex. 

Verruca. — The  common  wart,  originating  in  an  elongation 
of  the  papilla?  of  the  skin.  Verruca  mollis :  connective-tissue 
wart  with  a  broad  base  and  covered  with  a  thin  layer  of 
epithelium. 

Papilloma.  —  Cauliflower  growth,  tree-shaped,  branched 
papillae,  thickly  covered  with  epithelium.  'Apt  to  become 
cancerous. 

Glandular  Hypertrophies,  retaining  an  even  disposition  of 
their  parts,  occur  often  in  the  lymphatic  glands  (Lymphoma), 
and  in  the  spleen.  Also  in  the  thyroid  gland  (Struma  hyper- 
plastica),  in  the  mammae,  and  in  the  prostate  gland. 


50  GENERAL    PATHOLOGY. 

Retention  Cysts,  so-called,  are  due  to  the  partial  or  complete 
retention  of  secretion  in  glands  which  open  on  the  surface. 
These,  also,  cause  a  certain  hypertrophy  of  the  expanded 
constituents  of  the  glands.  One  of  the  most  frequent  is  the 
Atheroma  of  the  scalp,  due  to  the  distended  condition  of  the 
entire  follicular  sheath  of  a  hair ;  further,  the  mucous  polypi 
of  the  intestines  and  uterus.  Small  outgrowths  upon  the 
ventricular  surfaces  of  the  brain  are  sometimes  described. 

//.  Heteroplastic  Tumors. 

(Tumors  in  the  slrict  sense  of  the  word.) 

A.  Tumors  derived  from  the  blood-vessel  and  connective- 
tissue  apparatus  (Paraplastic  heteroplasms  ;  Virchow's  His- 
tioids). 

1.  Complete  Development  of  Tissue  : — 

(a)  Fibroma. — Consists  of  dense,  thickly-interwoven  con- 
nective tissue  fibres,  and  has  many  and  often  large  blood 
vessels.  Proceeds  from  organized  strata  of  connective  tissue, 
from  fascial  membranes,  from  the  external  layer  of  the  perios- 
teum, from  nerve  sheaths,  more  rarely  from  interstitial  con- 
nective tissue.  The  Myo-fibroma  is  an  important  subdivision, 
being  the  chief  tumor  of  the  uterus,  where  it  appears  periphe- 
rally, forcing  its  way  up  into  the  abdominal  cavity ;  intersti- 
tially,  or  as  a  sub-epithelial  tumor,  the  so-called  fibroid  poly- 
pus. If  the  process  extend  along  the  track  of  a  blood  vessel 
or  nerve,  it  receives  the  name  of  plexiform  fibroma. 

(6)  Lipoma. — Consists  of  lobules  of  fat,  which  are  often 
united  by  means  of  the  blood  vessels,  into  a  large  round 
tumor.  It  is  found  almost  always  in  the  fatty  layer  of  the 
true  skin,  especially  on  the  shoulder. 

(c)  Enchondroma. — -Consists  of  pieces  of  cartilage,  of  the 
size  of  a  hemp-seed,  bound  together  by  the  connective  tissue 
into  a  lobulated  tumor.     It  occurs  in  large  numbers  in  the 
bone-marrow  of  the  fingers,  and  in  the  joints,  forming  round 
lumps,  which    distend  the   bony   cortex.     On  the  humerus, 
femur,  malar  bones  and  ribs,  they  arise  from  the  periosteum, 
and  spread  equally  in  all  directions. 

(d)  Myxomi. — In  many  cases  only  a  mucoid-degenerated 
Lipoma,  Enchondroma,  or  Fibroma.     Nevertheless,  primary 
mucous  tissue  tumors  exist,  which  arise  in  the  subcutaneous 


TUMORS.  51 

connective  tissue,  and  in  the  connective  tissue  of  the  nervous 
system. 

(e)  Angioma. — We  distinguish  Telangiectasis,  the  birth- 
mark, which  owes  its  origin  to  a  circumscribed  lengthening, 
expansion,  and  thickening  of  the  capillaries.  Furthermore, 
the  cavernous  fibroma,  which  depends  upon  a  similar  dilata- 
tion of  the  lumen,  with  fibroid  metamorphosis  of  the  walls 
and  of  the  intermediary  parenchyma,  as  in  the  formation 
of  corpora  cavernosa.  Lastly,  Lymphangioma,  a  local  dila- 
tation of  the  lymphatics,  leads  to  the  formation  of  macro- 
glossus  ;  otherwise  rarely  found. 

(/)  Otteoma. — Results  from  the  ossification  of  connective 
tissue  tumors. 

(g)  Etidothelioma. — On  a  scanty  connective-tissue  stroma 
the  endothelial  layers  accumulate  and  form  hard,  spherical 
tumors,  particularly  in  the  walls  of  the  subdural  space  of  the 
skull. 

Tumors  which  are  composed  of  a  large  number  of  muscle  or  nerve  fibres  are  true 
Mvomatu  or  Neuromata.  Concerning  the  origin  of  these  very  rare  tumors  nothing  in 
known.  What  is  generally  termed  Myoma  or  Neuroma  are  Fibromata  or  Sarcomata, 
containing  muscular  or  nervous  tissue. 

2.  Incomplete  Development  of  Tissue.     Sarcoma : — 

(a)  Small,  Spindle-celled  Sarcoma.  —  Consists  entirely  of 
spindle  cells  of  equal  size,  not  exceeding  in  average  length 
and  thickness  the  spindle  cells  of  cicatricial  tissue.  Arranged 
in  bundles,  they  form  a  dense,  elastic,  rather  exstructive 
tumor,  arising,  like  fibroma,  from  completely  developed  con- 
nective tissue.  (Fasciae,  membranes,  periosteum.) 

(6)  Large  Spindle-celled  Sarcoma. — Distinguished  by  the 
presence  of  exceedingly  large  and  often  very  thick  multi- 
nuclear  spindle  cells.  These  form  loose  bundles,  radiating 
from  one  or  many  centres.  The  long  offshoots  form  a  network, 
in  which  large  round  multinuclear  cells  are  lodged.  Fully 
developed  connective  tissue  and  the  interstitial  connective 
tissue  of  some  glands  form  a  favorite  nidus  for  these  nuclei. 

(c)  Granulation-like  Round-celled  Sarcoma. — Occurs  in 
loose  sub-serous,  sub-mucous,  retro-peritoneal,  mediastinal,  in- 
ter-muscular connective  tissue ;  in  short,  in  almost  any  inter- 
stitial connective  tissue.  The  numerous  varieties  of  the  same 
are  determined  by  the  seat  of  their  growth.  Sarcoma  myxoma- 
todes  forms  in  the  retro-peritoneal  connective  tissue  a  tumor  as 
large  as  a  man's  head.  Sarcoma  lipomatodes  produces  extensive 


52  GENERAL    PATHOLOGY. 

tumors  in  the  fatty  layer  of  the  skin,  a  favorite  seat  being  the 
thigh.  Sarcoma  m elanodes  arises  from  the  choroid  coat  of  the 
eye,  or  from  the  skin.  Giant-celled  sarcoma,  distinguished  by 
the  presence  of  giant  cells  containing  many  nuclei,  occurs  in 
the  bone  marrow.  Osteoid  sarcoma  produces  an  incomplete 
osseous  tissue,  which  is  distributed  throughout  the  tumor  in 
radiated  or  porous  masses.  It  arises  from  the  inner  perios- 
teum. Glioma  proceeds  from  the  round  cells  of  the  neuroglia  of 
the  brain  and  the  retina,  and  preserves,  in  a  peculiar  manner, 
the  character  of  the  mother  tissue.  Cartilaginous  sarcoma  is 
really  nothing  but  a  sarcomatously  degenerated  enchondroma, 
found  chiefly  in  the  testicles.- 

Sometimes  such  a  superabundance  of  cells  occurs  in  tumors  that  the  round  cells  resolve 
themselves  into  small  and  large  groups,  which,  being  emptied,  resemble  alveoli  (Sarcoma 
olvei-lare).  Even  without  the  formation  of  alveoli,  this  tumor  can  reach  the  highest 
degree  of  softness  (almost  a  pus-like  infiltration).  Sarcoma  medullare. 

(d)  Lymphadenoid  Hound-celled  Sarcoma,  or  malignant 
Lymphoma,  arises  primarily  in  a  lymphatic  gland,  but  soon 
escapes,  spreading  in  different  directions.  A  large-celled 
variety  is  sometimes  found. 

B.  Tumors  whose  essential  constituents  proceed  from  surface 
or  gland  epithelium  (Epitheliomata.  Archiplastic  hetero- 
plasms.) 

1.  Squamous  Epithelioma. — Arises  from  free  surfaces  cov- 
ered with  squamous  epithelium.     Epithelial  cancer  of  the  skin 
consists,  apart  from  its  often  very  vascular  stroma,  of  cylin- 
drical, cancerous  bodies  containing  only  squamous  epithelium 
arranged  in  layers,  in  the  centre  of  which  pearly  bodies  are 
found.     This  cancer  occurs  in  places  which  are  especially 
subjected  to  external  irritation,  as,  for  instance,  on  the  hands, 
tibia,  scrotum,  lips,  ears,  face,  penis,  and  vulva.      It  is  inti- 
mately connected  with  cancer  of  the  tongue  and  oesophagus. 
The  former  spreads  rapidly  by  means  of  the  lymphatics  of 
the  tongue,  the  latter  is  noticeable  in  the  stricture  produced 
in  the  oesophagus.    Carcinoma  recti  is  a  squamous  epithelioma, 
as  also  carcinoma  vesicce  urinarice. 

2.  Cylindrical  Epithelioma. — Found  along  the  whole  intes- 
tinal tract,  as  well  as  on  the  os  uteri.     Carcinoma  fungosum 
ventriculi  (fungoid  cancer  of  the  stomach),  which  is  the  most 
common  of  all  the  stomach  cancers,  is  distinguished  by  stenosis 
and  ectasia  of  the  stomach,  later  by  hemorrhages  resembling 


TUMORS.  53 

coffee  grounds,  and  by  metastasis  to  the  liver.  Here,  also, 
belongs  cancer  of  the  intestines  and  rectum,  characterized  by 
the  production  of  fatal  strictures. 

3.  Glandular  Epithelioma. — There  are,  in  glandular  epithe- 
lioma,  so  many  transition  forms  from  simple  and  cystic  gland- 
ular hypertrophies  (see  above),  in  all  their  stages  of  irregularity 
and  imperfection,  up  to  the  most  luxuriantly  growing  cancers, 
that  it  is  no  easy  matter  to  clearly  define  the  adenoma,  cysto- 
adenoma,  cystosarcoma,  cystoid,  etc.  The  classification  varies 
in  different  glands. 

In  the  mamma  there  occurs  often  a  true,  usually  double- 
sided,  hypertrophy  of  the  whole  organ.  Adenoma  mammae, 
designates  certain  isolated  lumps,  in  which  a  more  abundant 
connective-tissue  formation  has  taken  place,  in  connection 
with  a  moderate  increase  of  epithelial  constituents.  This  new 
formation,  when  spread  over  the  whole  organ,  and  permeated 
by  a  leafy,  papular  overgrowth,  which  fills  in  the  cystic  dilated 
lumen  of  the  lactiferous  ducts,  is  called  cystosarcoma  pro- 
liferum,  or  phyllodes.  All  atypical  outgrowths  of  the  epithe- 
lium, on  the  other  hand,  are  classified  among  the  true  cancers. 
In  scirrhus  mammce,  the  epithelial  outgrowths  gradually  fill 
up  the  connective-tissue  interstices  and  lymphatics ;  in  soft 
cancer  of  the  mamma,  the  connective  tissue  yields  before  the 
powerful  advance  of  the  epithelial  masses. 

Adenoma  in  the  liver  is  an  outgrowth  of  the  network  of 
liver  cells,  consisting  of  solid  or  hollow  aggregations  of 
epithelial  cells,  the  whole  assuming  the  form  of  a  sphere  and 
being  inclosed  in  a-  connective-tissue  capsule.  Carcinoma 
hepatis  shows  a  direct  transformation  of  liver  cells  into 
cancer  cells,  or  (in  metastatic  cancer)  a  cell  overgrowth  in  the 
lumen  of  the  blood  vessel,  which,  beginning  at  numerous  indi- 
vidual points,  results  in  an  equal  number  of  cancerous  masses. 

Three  different  varieties  of  cancer  are  found  in  the  stomach. 
The  first,  very  soft  and  easily  disintegrated  ;  the  second,  very 
hard  (scirrhus),  with  a  cicatricial  formation  of  the  stroma  ; 
the  third,  colloid,  with  a  gelatinoid  degeneration  of  the  cancer 
cells. 

The  glands  of  the  uterus  produce  the  common  cancer  of  the 
cervix  and  the  rarer  cancer  of  the  uterus  proper.  Adenoma 
is  not  found  here.  Cancers  are  also  found  in  the  prostate  and 
salivary  glands,  and  in  the  lungs.  An  adenoma  of  the  parotid 
gland  also  occurs. 


54  GENERAL    PATHOLOGY. 

In  the  ovary  we  find  an  exceedingly  important  cyst,  in 
reality,  an  adenoma.  Its  normal  structural  parts  being 
already  little  cysts,  the  cystic  character  found  here  is  not 
surprising.  True  cancer  of  the  ovary,  which  occurs  much 
more  rarely,  readily  becomes  cystic,  although  this  is  chiefly 
due  to  the  softening  of  large  cancer  masses.  In  the  testicle 
the  cystosarcoma  testis  resembles  the  sarcoma  more  than 
the  carcinoma.  A  sarcomatous  overgrowth  of  the  interstitial 
connective  tissue  causes  a  partial  compression  and  retention 
ectasis  of  the  seminal  ducts.  Even  cancers  are  regularly 
provided  with  a  soft  sarcomatous  stroma,  forming  a  combina- 
tion tumor  which  could  be  called  with  equal  justice  sarcoma 
carcinomatosum,  or  carcinoma  sarcomatosum. 

In  the  kidneys  only  true  cancer  is  found.  It  spreads  not 
only  to  the  pelvis  of  the  kidney  and  its  calyx,  but  also  to  the 
renal  vein,  and  to  the  inferior  vena  cava,  causing  in  the  former 
hemorrhage  of  the  kidney,  in  the  latter  cancerous  thrombi. 

The  so-called  dermoid  cysts  occupy  a  peculiar  position 
among  the  epitheliomata.  These  cysts,  as  large  as  a  man's 
head,  are  provided  with  a  tough  capsule,  and  are  found  in 
the  ovary,  testicle  and  connective-tissue  apparatus.  They 
exhibit  the  strange,  genetic  relationship  which  exists  between 
all  surface  and  gland  epitheliomata.  Upon  the  inner  sur- 
faces of  these  tumors,  glandular  epithelium  is  observed  in 
the  process  of  transformation  into  cylindrical  and  squamous 
epithelium,  with  all  its  local  peculiarities,  hair,  etc. 

This  summary  must  suffice  for  the  present.  For  a  more 
explicit  representation  of  tumors  and  of  the  processes  con- 
cerned in  inflammation,  I  will  refer  my  readers  to  my  Manual 
of  Pathology. 

(e)    BENIGN   AND   MALIGNANT   TUMORS. 

Regarding  tumors  as  local  and  degenerate  overgrowths,  I 
have  in  the  preceding  pages  classified  them  in  accordance 
with  that  standard,  which,  if  it  be  a  correct  one,  must  serve 
still  further  to  illustrate  the  relations  existing  between  the 
turnor  and  the  general  organism. 

We  distinguish  benign  and  malignant  tumors.  Beniyn 
tumors  are  those  which,  although  occasioning  some  discom- 
fort, may  exist,  without  positive  injury  to  the  organism. 
Malignant  tumors  are  those  which  exert  a  baneful  and  con 
stantly  increasing  influence  upon  the  organs  of  nutrition,  and, 
finally,  bring  about  their  complete  destruction. 


TUMORS.  55 

No  tumor  can,  of  course,  be  benign  in  the  sense  of  healthful. 
A  benign  tumor  may,  from  its  locality,  become  dangerous,  and 
under  the  most  favorable  conditions  a  benign  tumor  exhibits 
an  intensity  of  growth  which  must,  necessarily,  tax  the 
resources  of  the  organism.  This  is  seen  in  all  euplastic  (hy- 
perplastic)  tumors,  and  in  those  paraplastic  heterpplasms 
whose  constituent  tissues  reach  perfect  development,  such  as 
Fibroma,  Lipoma,  Enchondroma,  Myxoma,  etc. 

But  paraplastic  tumors  with  imperfect  tissue  development, 
as  well  as  most  epithelial  tumors,  may  be  recognized  as  malig- 
nant tumors.  We  thus  arrive  at  a  distinct  line  of  demarca- 
tion between  malignant  and  benign  tumors.  That  we  do  not 
deal  here  with  superficial  coincidences,  but  with  a  separation 
deduced  from  the  nature  of  our  classification,  will  appear 
from  the  following  considerations : — 

We  found  that  an  overpowering  amount  of  cell  production 
is  apparently  the  only  purpose  of  that  intense  process  of 
degenerate  growth  seen  in  the  Sarcoma  and  Carcinoma.  This 
enormous  productivity  forces  the  young,  new-formed  cells  to 
usurp  all  the  available  space  in  and  around  their  place  of 
origin.  The  young  cells  penetrate  into  every  crevice,  invade 
every  pore  of  the  structure,  and  infringe  upon  the  parenchyma 
cells  and  connective-tissue  fibres,  which  are  at  length  crowded 
out  and  obliterated  by  the  irresistible  force  of  the  new  growth. 
It  is,  therefore,  with  justice,  that  Sarcomata  and  Carcinomata 
are  designated  as  undermining  and  destructive  tumors  as  com- 
pared with  the  more  constructive  varieties.  The  especial 
characteristic  of  malignity  is  destructiveness. 

Very  conspicuous  among  the  interstices  into  which  destruc- 
tive tumors  send  their  brood  of  young  cells  are  the  lymphatics 
and  their  beginnings.  These  are  large  enough  to  give  free 
passage  to  the  cells  which  reach  them  from  the  periphery,  and 
to  conduct  them  as  far,  at  least,  as  the  nearest  lymph  gland. 
Here  they  are  arrested  by  the  delicate  reticulum  of  lymph- 
adenoid  tissue,  but  find  in  it  a  supply  of  nutrition  admirably 
adapted  to  their  growing  needs.  They  are  surrounded  by  a 
soft,  porous,  vascular  tissue.  Attaching  themselves  to  the 
blood  vessels,  they  begin  at  once  a  vigorous  growth,  and  soon 
the  entire  lymph  gland  is  converted  into  a  mass  resembling 
the  parent  tissue.  After  this  the  constituents  of  the  tumor 
pass  by  means  of  the  communicating  lymph  paths,  unopposed, 
into  the  venous  and  arterial  systems.  The  lungs  are  next 


56  GENERAL   PATHOLOGY. 

chosen  as  a  seat  for  colonies  of  young  tumor  cells,  and  the  so- 
called  metastatic  tumors  ;  after  this  all  of  the  organs  of  the 
body,  noticeably,  the  spleen,  liver,  bones  and  connective-tissue. 

The  process  thus  described  is  the  typical  plan  of  attack 
pursued  by  malignant  tumors  in  their  rude  invasion  of  the 
organism.  The  involvement  of  the  neighboring  lymph 
glands,  and  the  appearance  of  metastatic  tumors,  betokens 
the  malignity  of  the  tumor,  and  is  a  valuable  guide  in  the 
diagnosis. 

A  much  more  dangerous  and  important  invasion,  which 
begins  earlier  and  which  is  of  greater  continuity  and  intensity 
than  that  made  upon  the  cells,  is  the  admixture  of  the  liquid 
products  of  metamorphosis  which  form  in  the  tumor  and  are 
absorbed  by  the  lymphatics.  Although  little  is  known  of  the 
chemical  properties  and  other  characteristics  of  these  products, 
we  may  be^ure  that  they  are  actively  employed  in  undermin- 
ing the  entire  nutritive  apparatus  of  the  patient.  They  are, 
probably,  fermentative  substances  which  act  upon  the  albu- 
men of  the  blood  in  the  same  manner  as  the  gastric  juice, 
dissolving  it  and  impeding  its  reproduction.  For  the  most 
prominent  symptom  of  that  blood  cachexia,  which  is  certain 
to  result  fatally,  is  the  increasing  impoverishment  of  the 
blood,  in  respect  to  its  free  and  fixed  corpuscular  elements. 

This  description  of  the  incorporation  and  diffusion  of  a 
malignant  tumor  in  the  system  somewhat  anticipates  my  gen- 
eral plan.  Metastasis  and  cachexia  are  properly  deutero- 
pathic  symptoms.  A  more  complete  system  of  arrangement 
will  be  possible  in  the  Second  Part. 


II.  THE  ANATOMICAL  DISTRIBUTION 
OF  DISEASE. 

DEUTEROPATHIC  GROUPS  OF  SYMPTOMS. 


INTRODUCTION. 

The  anatomical  changes  which  accompany  the  local  out- 
break of  disease  are  communicated  to  the  adjacent  organs  or 
to  the  entire  system.  Thus  arises  a  secondary  class  of  symp- 
toms, which  we  will  term  deuteropathic.  The  propagation  of 
disease  is,  accordingly,  direct  and  physical  (anatomical),  and 
is  consummated  in  various  ways.  It  is  of  prime  importance 
to  know  whether  the  original  seat  of  disease  generates  and 
throws  off  products,  which,  by  the  inter-communication  of  the 
lymphatics  and  blood  vessels,  are  transmitted  to  the  system  at 
large.  These  products  may  be  coarsely  constituted,  like 
aggregated  or  isolated  cells,  detached  fragments  of  coagulated 
blood,  etc.,  in  which  case  they  are  liable  to  collect  in  narrow 
and  impassable  blood  vessel  channels  and  produce  what  is 
known  as  metastasis. 

If,  however,  the  products  should  be  of  a  minute,  liquid,  or 
even  volatile  nature,  we  may  expect  them  to  become  inter- 
mixed with  the  blood  and  juices  of  the  body. 

The  reception  and  propagation  of  such  a  "  materies  peccans  " 
from  a  seat  of  disease  resembles,  in  many  respects,  the  recep-' 
tion  and  propagation  of  organic  or  mineral  poison,  infectious 
matter,  etc.;  both  processes  often  give  rise  to  similar  results. 
As  one  of  the  chief  of  these,  we  may  reckon  the  production 
of  fever.  The  central  nervous  system,  being  especially  sensi- 
tive to  blood-poisoning,  exhibits  certain  general  symptoms  of 
excitation  and  exhaustion,  which  form  another  typical  group. 
At  last  the  anatomical  composition  of  the  blood  begins  to 
suffer  from  this  constant  admixture  of  foreign  elements,  and 
this  deterioration,  joined  to  the  los^  of  cells  and  juices  in  the 
seats  of  disease,  results  in  a  general  decline,  or  a  cachexia  of 
the  body. 

5  57 


58  GENERAL   PATHOLOGY. 

A  local  affection  is  also  propagated  anatomically  through  a 
direct  attack  upon  the  nerves  of  the  diseased  part.  Every 
process  of  inflammation  and  reproduction  claims  a  certain 
amount  of  space  for  its  solid  and  liquid  products.  The  space 
furnished  by  a  closed  parenchymatous  organ  is  soon  filled,  an/1 
every  additional  deposit  leads  to  a  mechanical  pressure  upon 
the  nerves  of  the  organ.  This  takes  place  soonest  in  organs 
rich  in  nerves  and  deficient  in  flexibility,  as  in  the  serous 
membranes,  periosteum,  skin,  etc.  The  local  nerve  irritation 
thus  produced  culminates  in  pain,  and  this  cardinal  symptom 
may  also  bring  in  its  train  a  number  of  other  nervous  symp- 
toms, ranging  from  the  slightest  sympathetic  affections  to  the 
most  severe  neuralgias  and  cramps. 

METASTASIS. 

When  a  local  disease,  Avhich  is  of  some  standing  and  un- 
mistakably primary  in  origin,  is  followed  by  another  similar 
disease  in  a  more  or  less  distant  locality,  the  physician  says 
that  the  disease  has  produced  a  metastasis.  The  same  disease 
can  form  not  only  one,  but  many  metastases,  which,  in  turn, 
may  again  produce  metastases,  etc.  This  fact  reveals  an  ex- 
tensive similarity  between  all  metastasis-producing  diseases, 
for  certain  appearances  are  observed  which  are  typical  of 
certain  anatomical  arrangements,  and  result  from  the  trans- 
mission of  disease-producing  fragments  through  the  blood 
vessels  and  lymphatics. 

We  can  distinguish  sharply  enough  the  metastases  trans- 
mitted by  the  blood  paths  from  those  transmitted  through  the 
lymphatics.  The  lymphatics  are  so  arranged  and  constituted 
by  nature  that  they  are  able  to  take  up  even  solid  fragments, 
i.  e.,  wandering  cells  of  the  parenchyma.  A  minute  sub- 
division of  the  corpuscular  products  in  the  primary  seat  of 
disease  is  all  that  is  necessary  to  secure  their  entrance  into 
and  transmission  through  the  lymphatics.  The  blood  vessels, 
on  the  other  hand,  have  closed  walls,  and,  in  order  to  effect  a 
migration  through  them  from  one  seat  of  disease  to  another, 
the  product  must  have  been  generated  within  their  lumen,  have 
grown  through  or  been  forcibly  introduced  into  their  walls.  For 
this  reason  metastasis  through  the  blood  vessels  shows  a  certain 
sameness  in  the  products  transmitted.  Most  important  are : 
blood  clots,  derived  from  the  veins  of  the  primary  growth ; 


METASTASIS.  59 

air  and  fat,  which,  under  particularly  favorable  circumstances, 
in  the  case  of  fresh  wounds,  can  penetrate  into  the  veins;  and, 
finally,  intestinal  worms  or  large  pieces  of  tumor,  which,  by 
some  accident,  have  broken  into  a  vein  (cancer  of  the  veins). 

(a)  Metastasis  through  the  lymphatics. — It  is  well  known 
that  the  art  of  tattooing,  which  is  not  confined,  by  any 
means,  to  Indians  alone,  is  effected  by  pricking  the  skin  with 
sharp  needles  and  rubbing  forcibly  into  the  fresh  wound 
minutely  subdivided,  but  insoluble  dye-stuffs  (Cinnabar  or 
Prussian  blue.)  A  part  of  this  dyestuff  remains  in  the  con- 
nective tissue,  the  rest  reaches  the  lymphatics,  by  which  it 
is  carried  further.  Having  gained  the  lymphatic  gland,  it 
even  penetrates  the  capsule,  but  is  then  arrested.  These 
brilliant  particles  remain  for  years  in  the  terminal  bulbs 
of  the  lymphadenoid  tissue,  partly  closed  in  by  cell  proto- 
plasm and  fibrous  tissue.  The  material  is  apparently  too 
heavy  and  rough  to  pass  unarrested  through  the  fine  and 
convoluted  lymphatic  paths  into  the  interior  of  the  gland. 
The  same  happens  to  all  minutely  subdivided  particles  which 
have  in  any  way  entered  the  lymphatic  vessels  at  some  point 
on  their  periphery.  The  effect  of  these  intrusions  into  the 
lymphatic  ducts  is,  of  course,  very  different  from  the  simple 
tolerance  of  the  gland  substance  for  all  those  unchangeable, 
and  consequently  chemically  bland  particles,  like  coal-dust, 
iron -dust,  stone-dust,  etc. 

Some  of  the  wandered-out,  colorless  blood  corpuscles  are 
invariably  carried  from  an  inflamed  centre  to  the  neighboring 
lymphatic  glands.  In  consequence  of  this,  the  local  lymph 
paths  swell  so  quickly  and  to  such  an  extent  that  the  secondary 
(deuteropathic)  suffering  really  exceeds  the  primary  (proto- 
pathic).  The  nerve  sheaths  being  particularly  pressed  upon, 
pain  results,  which  is  increased  by  the  slightest  touch  or  move- 
ment of  the  neighboring  organs. 

As  the  inflammation  diminishes,  the  swelling  of  the  local 
glands  also  subsides.  The  cells  which  have  wandered  in  have 
meanwhile  either  found  their  way  out  or  been  overtaken  by 
fatty  degeneration.  Often,  however,  things  do  not  run  so 
smoothly.  The  irritated  gland  becomes  inflamed,  and  the 
formation  of  pus  and  abscesses  inevitably  follows.  We  must, 
then,  provide  for  an  early  evacuation  of  the  pus,  lest  this 
metastatic  centre  again  cause  others. 

We  have  already  laid  stress  upon  the  fact  that  the  metas- 


60  GENERAL    PATHOLOGY. 

tasis  of  malignant  tumors  by  means  of  the  lymphatic  system 
is  very  prominent. 

(b)  Metastasis  through  the  blood  vessels. — We  have  men- 
tioned above,  briefly,  the  conditions  necessary  to  a  metastasis 
through  the  blood  vessels.  The  blood  vessels,  according,  to 
Harvey's  memorable  discovery,  are  completely  closed  in, 
and  not  intended  for  the  reception  of  solid  particles  of 
the  bodily  parenchyma;  hence,  only  such  solid  bodies  can 
be  transmitted  from  one  point  to  another,  as  have  been 
produced  in  the  lumen  of  the  blood  vessel,  or  have  been 
forcibly  introduced  through  their  walls.  Whence  the  ex- 
treme rarity  of  cases  of  metastasis  of  heterogeneous  substance. 
We  will  first  consider  the  metastasis  of  blood  clots,  which  have 
been  formed  in  the  blood-vessel  apparatus,  and  carried  away  by 
the  blood  current,  and  also  examine  the  doctrine  establishe  I 
by  Virchow  concerning  thrombosis  and  embolism  of  thrombi. 

COAGULATION   OF  STAGNATING   BLOOD. 

Blood  coagulates  so  soon  as  it  is  cut  off  from  the  general 
circulation  and  becomes  stationary.  If  we  open  a  vein  in  an 
animal,  catch  the  blood  in  a  glass,  and  allow  it  to  remain  station- 
ary for  a  few  minutes,  we  notice  that  the  blood  is  transformed 
into  a  dark  red  jelly,  which,  in  the  course  of  a  day,  gradually 
sinks  to  the  bottom  of  the  glass,  having  diminished  one-fifth 
in  volume.  In  the  meantime,  a  yellowish-colored  clear  liquid 
collects  above  the  clot,  and  if  evaporation  is  prevented,  rises  in 
the  glass  to  the  original  level  of  the  blood.  The  fibrin  has 
coagulated,  and  with  it  the  blood  corpuscles  are  fixed  ;  then, 
having  contracted  upon  its  contents,  a  portion  of  the  blood 
serum  has  been  squeezed  out. 

By  the  use  of  the  microscope,  we  learn  the  following  con- 
cerning the  process  : — 

Let  us  suppose  a  drop  of  blood  taken  from  the  finger,  allowed 
to  run  into  the  capillary  space  between  a  glass  slide  and  thin 
glass  cover,  and  placed  'immediately  under  the  microscope.  At 
once,  even  while  the  blood  corpuscles  are  settling,  we  see  that 
peculiar  aggregation  which  leads  to  the  formation  of  the  well 
known  rouleaux  and  other  less  marked  shapes.  In  the  course 
often  or  fifteen  minutes,  those  groups  and  chains  of  blood  cor- 
puscles unite  and  form  a  kind  of  network  of  red  bands  with 
intermediate  circular  gaps.  The  whole  resembles  a  coarse 
sponge,  and  it  is,  undoubtedly,  this  sponge,  formed  also  largely 


THROMBOSIS.  61 

in  blood  pi'ocured  by  venesection,  which,  by  its  continued  con- 
traction, presses  out  the  enclosed  serum. 

Although  we  know  that  fibrin  is  the  active  principle  in  this 
contraction,  we  are  unable  to  see  it  without  further  prepara- 
tion. In  order  to  effect  this,  we  put  a  little  of  a  f  %  salt  solution 
at  the  edge  of  the  cover  glass,  and  wash  the  clot  thoroughly 
by  compressing  it  between  the  cover  and  slide.  The  blood 
corpuscles  disappear  in  the  washings  and  the  fibrin  remains 
outspread,  resembling  a  veil-like  tissue,  between  the  slide  and 
cover.  Upon  examination  of  the  most  delicate  lamellfe,  we 
see  that  the  form  and  size  of  the  blood  corpuscles  have 
determined  the  form  and  size  of  the  mesh  which  composes  the 
granular  fibrous  network.  The  secretion  has  taken  place  on 
the  surface  of  the  blood  corpuscles,  and  united  the  same  into 
11  coarse,  spongy  structure. 

THROMBOSIS    IN    VEINS. 

When  a  portion  of  a  blood  vessel  is  cut  off  permanently 
from  the  general  circulation,  the  blood  within  it  coagulates 
in  the  same  manner  as  when  drawn  directly  from  a  vein.  If 
the  lumen  of  an  artery  is  obliterated  by  a  ligature,  the  whole 
mass  of  blood  coagulates  both  upward  and  downward,  until 
the  first  collateral  branches  are  reached.  This  is  the  simplest 
form.  In  the  study  of  metastases  we  have  first  to  consider 
that  stagnation-thrombosis  which  is  produced  in  tmcollapsed 
veins  when  the  blood  current  is  insufficient  or  absent.  Many 
organs  have,  by  nature,  veins  which  do  not  collapse.  In  the 
sinuses  of  the  brain,  for  example,  a  considerable  diminution 
in  the  force  of  the  heart,  as  in  extreme  debility  taken  in  con- 
junction with  continued  bodily  rest,  causes  the  blood  to  coagu- 
late in  certain  recesses  and  deepest  parts  of  the  sinus  cavernosi 
(marantic  thrombi).  In  other  organs  a  preceding  inflam- 
mation furnishes  the  cause  and  material  for  a  firm  infil- 
tration of  the  connective  tissue  which  surrounds  the  veins  and 
their  walls.  The  vein  wall  is  of  itself  relaxed,  and  can  be 
readily  compressed  or  folded  together.  If,  for  instance,  we 
have  amputated  the  leg  above  the  knee,  we  expect  the  large 
veins  which  have  been  severed  to  collapse,  and  to  remain 
firmly  closed  under  the  ligature.  There  exist  now,  as 
before,  numerous  anastomoses  with  the  surrounding  veins  of 
the  skin  and  muscles,  but  the  pressure  in  these  tributary  veins 
is  too  slight  to  force  the  blood  outside  its  normal  paths  of 


62  GENERAL   PATHOLOGY. 

exit  through  the  now  disused  paths  of  exit  of  the  lower  thigh. 
The  blood  docs  not  return  from  the  external  iliac,  through 
the  crural  vein,  on  account  of  the  numerous  valves  which 
are  there  present. 

This  condition  of  things  is,  however,  altered  if  a  powerful 
and  deep-seated  inflammation  attack  the  stump.  I  refer  par- 
ticularly to  that  extremely  hard,  inflexible  infiltration  of  the 
interstitial  connective  tissue,  which  is  produced  by  a  diph- 
theritic or  erysipelatous  infection.  This  process  is  especially 
liable  to  locate  itself  in  the  walls  of  the  veins,  converting  the 
same  into  thick,  inflexible  tubes  (phlebitis).  If  these  veins 
be  divided  transversely,  they  can  scarcely  be  distinguished 
from  the  adjacent  arteries.  The  veins  are  kept  open  by  this 
dense  inflammatory  infiltration  of  their  adventitia,  just  as  the 
arteries,  by  reason  of  their  thick  muscular  coat,  remain  open. 
In  proportion  as  these  changes  advance,  the  collapsed  lumen 
dilates  anew,  and  is  replenished  with  blood  from  the  surround- 
ing circulatory  vessels.  This  opening  up  of  the  ends  of  the 
veins  is  part  of  the  mechanism  of  infiltration.  The  blood  is 
sucked  in.  Just  as  soon  as  the  blood  which  has  been  drawn 
into  the  comparatively  empty  spaces  has  come  to  rest,  coagu- 
lation takes  place.* 

The  phenomena  in  puerperal  inflammation  of  the  uterus 
show  us  another  modification  of  stagnation-thrombosis.  The 
veins  of  the  uterus,  so  long  as  they  run  entirely  in  its 
muscular  structure,  possess  no  markedly  distinct  walls,  but 
are  merely  gaping  openings  separated  from  the  neighboring 
bands  of  muscles  by  a  thin  connective  tissue  and  endothelial 

*  This  somewhat  new  description  of  the  setiological  sequence  of 
thrombosis  in  stumps  applies  to  most,  but  not  all  cases.  Often, 
indeed,  when  a  venous  thrombosis  has  been  established  without  pre- 
ceding inflammation,  conditions  unfavorable  to  the  efflux  of  venous 
blood,  such  as,  malpositions  of  the  stump,  compression  of  the  ex- 
ternal iliac  by  swollen  glands,  heart  failure,  etc.,  are  sufficient  to  fill 
the  empty  venous  trunks  of  the  upper  part  of  the  thigh  with  stag- 
nating blood.  Coagulation  now  usually  begins  in  the  sinuses  of  one 
or  more  of  the  valves,  and  extends  thence  into  the  lumen  of  the 
vein. 


We  must  always  remember,  in  this  connection,  that  when  the  large 
veins  of  the  upper  thigh  are  severed  from  their  connection  with 
those  of  the  lower  thigh,  the  source  of  the  power  by  which  they 


send  their  blood  to  the  heart  is  cut  off,  and  that  henceforth  these 
vessels  are  nothing  but  disproportionately  wide,  blind  appendages 
ot  the  circulatory  system. 


THROMBOSIS.  63 

lining.  They  remain  open  as  long  as  the  muscular 
structure  of  the  uterus  is  not  contracted,  but  when  con- 
traction takes  place  during  labor,  they  close,  so  that  a  well 
contracted  uterus  possesses  in  reality  no  open  veins,  and,  in 
fact,  only  a  weak  circulatory  apparatus.  If  infection  and  in- 
flammation now  arise,  the  first  sign  of  the  latter  is  the  relaxa- 
tion and  renewed  expansion  of  the  uterus,  causing  its  venous 
trunks  again  to  open  and  blood  to  be  sucked  in  from  the  in- 
ternal iliac  vein.  This  blood  returning  a  fronte  into  the 
vessels,  is  wanting  in  vis  a  tergo,  and,  consequently,  is  dis- 
posed to  stagnation  and  coagulation. 

The  above  description  of  the  two  most  important  forms  of 
stagnation-thrombosis  will  suffice.  Coagulation  occurs  here, 
as  in  venesection,  and  the  clot  becomes  dark  red  and  soft  in 
proportion  as  the  circulation  is  more  or  less  suddenly  and 
completely  arrested.  Such  properties  are  rarely  met  with, 
and  then  only  incompletely,  in  actual  cases  of  venous  thrombi. 
These  thrombi,  if  we  exclude  all  secondary  changes  which 
may  have  befallen  them,  are  generally  much  firmer,  more 
highly  colored,  and  much  more  irregular  in  shape  than  the 
clot  of  venesection.  Hence  simple  stagnation  does  not,  as  a 
rule,  cause  the  blood  to  coagulate,  but  under  its  influence 
certain  qualities  of  the  corpuscular  elements  of  the  blood 
manifest  themselves,  which  materially  complicate  the  process 
of  coagulation.  All  the  colorless  blood  corpuscles  are  active, 
sticky  cells,  their  viscidity  being  an  expression  of  their 
amoeboid  movement.  They  are  inclined  to  attach  them- 
selves to  every  firm  body  upon  which  they  impinge,  and 
having  done  so,  to  spread  out,  creep  into  small  existing 
openings,  or,  if  the  object  be  sufficiently  small,  incorpo- 
rating it  bodily.  As  long  as  they  remain  in  circulation 
they  have  no  opportunity  to  show  their  adhesive  tendency. 
They  are  carried  along  by  the  circulation,  which  rushes  them 
rapidly,  in  a  confused  mass,  first  through  the  heart,  then 
through  the  arteries  and  veins,  and  again  back  into  the 
heart.  As  the  result  of  such  great  mechanical  action,  they 
draw  themselves  together  with  a  kind  of  tonic  contraction, 
and  assume  the  shape  of  corpuscular  lumps  without  any 
apparent  individual  mobility.  When,  for  any  reason,  the 
blood  current  is  slowed,  or  even  entirely  stopped,  this  active 
stickiness  of  the  colorless  blood  corpuscles  reasserts  itself. 
They  collect  in  masses,  take  up  into  their  protoplasm  as 


64  GENERAL   PATHOLOGY. 

many  as  six  or  seven  red  blood  corpuscles,  and  glue  them- 
selves fast  to  the  walls  of  the  blood  vessel.  If  stagnation 
thrombosis  has  already  set  in,  they  at  once  rise  to  the  surface 
of  the  clot,  forming  here  a  continuous  covering.  If  a  new 
layer  of  blood  is  now  deposited,  the  above  process  is  repeated, 
which  affords  us  an  explanation  of  those  peculiarities  by 
which  we  distinguish  a  natural  venous  thrombus  from  one 
due  to  simple  bleeding,  or  from  a  ligation-thrombus. 

Those  corpuscles  described  by  Zimmermann,  and  which 
Bizzozero  has  recently  named  "  blood  plates  "  (Blutplattchen), 
also  take  an  active  part  in  this  process.  Like  the  colorless 
blood  corpuscles,  they  deposit  themselves  upon  every  caput 
mortuum  which  appears  in  the  blood  paths,  forming  those 
considerable  collections  of  granular  material  shown  by  the 
microscope  to  exist  in  all  new  and  old  venous  thrombi. 

This  stratified  arrangement  of  the  colorless  and  red  blood 
corpuscles  determines  not  only  the  structure,  but  also  the 
light  pinkish-white  color,  and  the  relative  toughness  and 
thickness  of  the  blood  clot. 

Should  the  new  theory  in  regard  to  the  secretion  of  a  fibrin 
ferment  by  the  leucocytes  be  established,  the  mere  presence  of 
a  body  covered  with  colorless  blood  corpuscles  and  located 
within  the  lumen  of  the  blood  vessel  would,  of  itself,  be  an  in- 
centive to  the  deposition  of  fresh  blood  layers,  and  may  be 
regarded  as  the  excitant  of  that  peculiar  growth  of  venous 
thrombi,  viz.,  growth  by  continued  coagulation.  It  is  well 
known'that  every  thrombus  has  a  tendency  to  grow  in  the 
direction  pursued  by  the  blood  current  which  passes  it.  The 
growth  results  from  the  deposition  of  fresh  clots  over  the 
whole  free  surface.  A  thrombus  grows  out  of  the  crural  vein 
into  the  external  iliac,  and  often  advances  as  far  as  the  inter- 
nal iliac.  From  the  uterine  veins  vegetations  derived  from 
thrombi  reach  the  trunk  of  the  inferior  vena  cava.  It  is  no 
rare  thing  to  find  a  thrombus  of  the  crural  vein  extending  up 
to  the  right  side  of  the  heart.  From  such  small  beginnings 
whole  areas  of  veins  can  thus,  under  favorable  conditions, 
become  obstructed.  Prolonged  thrombosis  is  a  more  inde- 
pendent link  in  the  chain  of  phenomena  which  we  are 
considering.  In  any  case,  it  should  not  be  treated  as 
stagnation-thrombosis,  because  it  arises  by  constant  conflict 
with  the  blood  current,  whose  paths  it  seeks  to  obstruct. 
Some  of  the  most  important  properties  of  venous  thrombi, 


THROMBOSIS.  65 

and  in  part  also  their  macroscopical  shape,  are  thus  ex- 
plained. 

The  original  stagnation-thrombus  depends  for  its  shape 
upon  the  shape  of  the  veins  in  which  it  originally  forms,  just 
as,  in  venesection,  the  glass  in  which  the  blood  is  caught 
determines  the  form  of  the  thrombus.  Suppose,  for  instance, 
that  a  thrombus  completely  fills  up  the  lumen  of  a  vein,  and 
extends  upwards  to  the  point  where  the  vein  empties  into  a 
still  larger  one.  The  first  vein  is  entirely  plugged  up  by  an 
obstructive  thrombus,  which  projects  slightly  into  the  cavity 
of  the  large  vein  by  means  of  a  slightly-flattened,  oval  head. 
Its  further  tendency  is  to  assume  first  the  hemispherical,  then 
the  spherical  shape,  by  which  the  lumen  of  the  large  vein  is 
rapidly  obstructed.  The  accomplishment  of  this  end,  how- 
ever, depends  entirely  upon  the  amount  of  blood  pressure 
existing  in  the  large  vein.  If  the  pressure  be  at  all  consider- 
able, the  projecting  head  of  'the  thrombus  is  impelled  towards 
the  heart,  against  the  side  of 'the  vessel  and  forced  to  assume 
the  shape  of  a  long  flat  tongue.  It  is  then  called  a  "  wall- 
adhering  "  thrombus. 

Wall-adhering  thrombi  may  attain  an  enormous  length, 
assuming  a  band-like  shape.  I  once  found  a  wall-adhering, 
band-like  thrombus,  7mm.  (.275  in.)  in  breadth,  which  ex- 
tended from  the  internal  iliac  vein  through  the  inferior  vena 
cava  up  to  the  heart.  This  band  showed,  in  parts,  a  distinct 
connective-tissue  metamorphosis  of  the  colorless  blood  cor- 
puscles of  which  it  was  composed  throughout.  Generally, 
the  wall-adhering  thrombus  becomes  thicker  and  thicker,  ob- 
structing veins  of  larger  calibre,  and  entirely  occluding  the 
flow  of  blood.  Cases  do  occur  of  incomplete  obstruction, 
where  the  blood  current  forces  its  way  in  a  spiral  manner 
along  the  side  of  the  thrombus.  This  spiral  passage  is,  after 
death,  generally  filled  with  freshly  coagulated  blood,  while 
the  thrombus  proper  is  of  a  white  or  reddish-white  color.  It 
is  apparent  from  all  this  that  the  narrowing  of  the  blood  paths 
in  thrombosis  increases  the  pressure  and  the  rapidity  of  the 
blood  current  in  the  remaining  parts  of  the  venous  system. 
In  this  conflict  between  the  thrombus  and  the  blood,  it,  un- 
fortunately, frequently  happens  that  a  mechanical  separation 
of  the  whole  or  portions  of  the  thrombus  takes  place.  In  the 
former  instance,  the  whole  thrombus,  being  propelled  by  the 
blood,  rolls  itself  up  into  a  roundish  mass  ;  in  the  latter,  small 


66  GENERAL    PATHOLOGY. 

fragments  are  detached  or  broken  off  from  portions  protruding 
too°boldly  into  the  free  lumen  of  the  vessel.  These  detached 
fragments  are  rapidly  swept  away  by  the  blood  current,  and 
become,  when  arrested  in  small  vessels,  emboli. 

The  subject  of  embolism  must  be  prefaced  with  a  few  ob- 
servations. Venous  thrombi,  before  they  are  carried  off  by 
the  current,  often  experience  a  series  of  changes  which  not 
only  further  the  act  of  detachment,  but  influence  their 
character  to  a  certain  extent,  and  determine  thereby  the 
quality  of  the  metastatic  process.  These  secondary  changes 
are  known  as  softening  of  thrombi.  Before  the  publication 
of  Virchow's  researches,  it  was  customary  to  speak  of  the 
suppuration  of  thrombi,  as  the  products  of  this  process  could 
hardly  be  distinguished  from  unhealthy  pus,  being  a  yellow- 
ish-gray emulsion  in  which  the  microscope  shows,  besides 
granular  detritus,  large  cells  resembling  pus  cells.  But,  how- 
ever definitions  may  vary,  the  .fact  still  remains  that  the 
softening  of  thrombi  takes  place  without  the  development 
of  new  elements,  and  may,  in  general,  be  regarded  as  a  mace- 
ration of  the  thrombus.  Only  in  rare  cases  (as  in  pyophle- 
bitis)  has  the  suppurative  inflammation  of  veins  appeared  to  me 
to  furnish  a  predominating  amount  of  white  blood  corpuscles 
which  found  their  way  into  the  lumen  of  the  vein.  In  most  cases, 
the  intima  of  a  vein,  although  not  smooth,  is  dry  and  firmly 
attached  to  the  outer  layer  of  the  thrombus,  while  the  puri- 
form  products  of  softening  have  their  seat  in  the  axis  of  the 
latter.  The  centre  of  the  clot  is  naturally  the  part  most 
completely  cut  off  from  the  general  nutritive  apparatus. 
It  is  the  exception  when  venous  thrombi  undergo  those 
organization  changes  which  take  place  as  a  rule  in  the 
ligation-clots  of  arteries  ;  neither  blood  vessels  nor  connective 
tissue  are  developed.  Everything  depends  upon  the  external 
supply,  and  as  this,  under  the  most  favorable  circumstances, 
can  only  penetrate  to  a  certain  very  limited  depth — about 
one  millimeter— a  centripetally  increasing  loss  of  nutrition 
ensues,  which  appears  in  the  chemical  solution  of  the  coagu- 
lated albuminous  bodies.  "We  may  assume,  then,  that  a 
putrid  fermentation  takes  place  in  a  pysemic  inflammation 
of  a  thrombus,  although  the  process  occurs  without  percepti- 
ble production  of  gas  or  smell. 

Externally,  much  depends  upon  the  layers  of  colorless 
blood  corpuscles,  which,  as  we  have  above  observed,  form  the 


THROMBOSIS.  67 

chief  ingredients  of  the  thrombus.  These  layers  resist  softening 
for  a  greater  or  less  period  of  time.  A  consistency,  at  first 
peculiarly  laminated,  afterwards  crumbling,  precedes  the 
complete  fusion  into  a  homogeneous  mass.  The  color  is  de- 
pendent upon  the  presence  of  red  blood  corpuscles  and  their 
metamorphosis.  The  uneven,  streaky  redness  of  the  fresh 
thrombus  is  replaced  later,  when  the  red  blood  corpuscles 
begin  to  lose  their  coloring  matter,  by  a  diffused  flesh-red 
and,  finally,  by  a  dirty  reddish  yellow.  The  superficial  sur- 
face of  a  thrombus  is  always  firm,  either  white  and  smooth, 
when  a  layer  of  colorless  blood  corpuscles  has  been  freshly 
deposited,  or  covered  with  a  bright  red  clot.  This  applies 
especially  to  such  thrombi  as  arise  in  the  tributaries  of  large 
veins,  viz.,  a  thrombus  of  the  saphena  vein,  which  projects 
into  the  vena  cruralis.  The  dome-shaped  protuberance  of 
such  thrombi  is  firm  externally,  but  the  firmness  extends 
scarcely  a  millimeter  in  depth ;  "below  this  point,  we  find  the 
centre  of  the  softening  process  which  produces  the  dome- 
shaped  exterior.  Everything  is  now  prepared  for  the  produc- 
tion of  a  metastasis.  A  sudden  pressure  exerted  upon  the 
vein  containing  this  thrombus  will  perhaps  burst  the  thin 
capsule,  the  rapid  blood  current  lends  its  aid,  and  the  next 
moment  the  head  of  the  thrombus,  the  softened  pulp,  and 
fragments  of  coagula,  are  hurrying  along  on  their  way  towards 
the  heart. 

THROMBOSIS   IN   THE  HEART   AND   ARTERIES. 

Next  in  importance  to  venous  thrombosis,  is  the  formation 
of  clots  in  the  heart  and  larger  arteries.  Endocarditis  and 
endoarteritis  produce  inequalities  upon  the  valves  of  the 
heart,  upon  the  intima  of  the  aorta,  and  the  smaller  arteries. 
Upon  these  inequalities  tiny  particles  of  blood  settle  and 
coagulate,  colorless  blood  corpuscles  are  deposited,  and  we 
have  the  nucleus  of  a  thrombus.  Its  development  is,  how- 
ever, much  less  rapid  than  in  the  veins,  because  the  force  of 
the  blood  current  in  the  heart  and  arteries  not  only  retards 
the  accumulation  of  new  material,  but  also  demolishes  the 
thrombus  as  soon  as  it  rises  upon  the  surface  of  the  blood 
vessel.  Of  this,  thrombosis  of  the  acutely  inflamed  valves  of 
the  heart  is  a  significant  example.  There  is,  accordingly,  no 
disease  which  makes  as  many  small  metastatic  inflammations 
as  acute  endocarditis. 


68  GENERAL    PATHOLOGY. 

Larger  thrombi,  or  heart  polypi,  never  develop  except  when 
the  discharge  of  blood  from  the  heart  is  incomplete,  in  stenosis 
and  when  there  is  diminished  muscular  power.  These  polypi 
are  often  carried  away  bodily.  A  thrombus  of  the  right 
auricle  extends,  for  instance,  with  the  blood  current,  into  the 
right  ventricle.  The  tricuspid  offers  no  obstacle,  and  the 
thrombus,  being  compressed  by  each  systole,  acquires  at  the 
point  of  repeated  compression,  a  constriction ;  in  the  right  ven- 
tricle, however,  the  thrombus  enlarges  in  a  nodular  manner. 
Finally,  we  have  a  body  of  the  size  of  a  walnut  projecting  by  a 
comparatively  slender  neck  from  the  auricle  into  the  ventricle. 
Each  repeated  systole  threatens  separation,  which  is  at  last 
effected  by  a  sudden  acceleration  of  the  heart's  action. 

Thrombi  of  the  ventricle,  after  reaching  a  certain  size,  say 
that  of  a  cherry,  are  apt  to  begin  to  soften  in  the  centre,  and 
when  the  softening  extends  to  within  half  a  millimeter  of  the 
surface,  burst  and  discharge  their  contents  directly  into  the 
heart  blood. 

EMBOLISM. 

We  have  now  noted  the  appearance  of  blood  clots  in  dis- 
eased bodily  organs  in  a  number  of  important  instances. 
We  found  "blood  stagnation  to  be  the  motive  power  for  the 
first  deposit,  and  the  viscidity  and  fibrination  of  the  corpus- 
cular elements  of  the  blood  to  be  instrumental  in  the  further 
growth  of  thrombi.  We  saw,  moreover,  how  fragments  of 
autochthonous  coagulation  could  be  detached  and  carried 
away  by  the  blood.  Their  further  destination  is  determined 
mainly  by  their  starting-point ;  thus  thrombi  in  the  general 
venous  system  and  hepatic  veins  traverse  the  right  heart 
and  reach  the  lungs ;  in  like  manner,  thrombi  in  the  right 
heart.  Thrombi  in  the  portal  system  are  arrested  in  the  liver, 
thrombi  in  the  pulmonary  veins,  left  heart,  aorta  and  large 
arteries  lodge  in  the  systemic  capillaries.  The  lungs,  which 
receive  thrombi  from  all  the  organs  of  the  body,  except  the 
intestines,  are  the  chief  metastatic  centres ;  next  in  frequency 
is  the  liver,  which  also  receives  arterial  blood,  and  which 
should,  to  all  appearances,  share  the  metastases  of  the  lungs 
and  left  heart  with  the  remaining  organs.  We  shall  soon  see, 
however,  that  this  division  is  an  unequal  one,  so  much  so  that 
the  brain,  spleen  and  kidneys  receive  the  lion's  share,  while  in 
all  other  organs  metastases  are  of  exceptional  occurrence. 


EMBOLISM.  69 

MIGRATING   THROMBI— LARGE   FRAGMENTS. 

Before  considering  the  arrest  of  blood  clots  and  the 
attendant  results,  we  must  make  a  more  careful  examination 
of  the  manner  of  their  migration.  Throw  into  a  swiftly- 
flowing  stream  a  large  and  irregularly-shaped  block  of  wood, 
and  you  will  see  it  revolve  swiftly  in  the  current,  until  it 
gains  a  definite  position  in  the  middle  of  the  stream,  after 
which  it  is  carried  forward  in  a  linear  direction.  If  the 
stream  divides,  the  block  follows  the  main,  or  most  direct, 
brunch.  This  hydro-dynamic  picture  will  serve  to  illustrate 
the  migration  of  large  clots  through  the  main  arterial  trunks 
of  the  body.  A  clot  leaving  the  left  ventricle  through  the 
aorta  passes  directly  into  the  right  carotid,  internal  carotid, 
and  middle  cerebral  artery,  where  the  sudden  contraction  of 
the  lumen  arrests  further  advance.  If  the  clot  is  too  large  to 
penetrate  into  the  lumen  of  the  innominate  artery,  it  follows 
the  arch  of  the  aorta  and  travels  in  a  linear  direction  through 
the  descending  aorta,  external  iliac  and  crural  arteries,  into 
the  popliteal,  where  it  becomes  lodged  immediately  above  the 
point  where  the  tibials  are  given  off. 

Blood  clots  which  have  reached  the  trunk  of  the  pulmo- 
nary artery  generally  follow  the  main  descending  branches. 
This  course  may  be  determined  by  the  laws  of  gravity,  but 
the  long  radiating  trunks  are  always  preferred.  Accordingly, 
the  metastatic  centres  in  the  lungs  are  situated,  almost  without 
exception,  superficially  in  the  lower  lobes. 

THE  BREAKING  DOWN  OF  THE  EMBOLUS. 

Large  thrombi  may  break  down  in  the  course  of  migration. 
Old  and  partially  macerated  thrombi  are  extremely  brittle. 
When  a  fragment  arrives  at  the  point  where  a  large  artery 
bifurcate*,  and  is  too  large  to  enter  either  branch,  it  is  stopped 
at  the  point  of  bifurcation  called  by  Virchow  the  spur.  But 
the  current  breaks  the  thrombus,  and  the  fragments  pass  both 
into  the  right  and  left  channels.  The  blood  often  washes 
away  small  particles  from  a  large  clot  into  one  channel,  leav- 
ing the  nucleus  small  enough  to  pass  into  the  other  branch. 
This  process  may  be  repeated  until  a  large,  simple  thrombus 
is  resolved  into  numberless  fragments.  Thus,  we  may  easily 
explain  the  circumstance  that  numerous  metastatic  centres 


70  GENERAL    PATHOLOGY. 

are  frequently  formed  in  the  same  lobe  of  the  lung,  in  the 
same  Malpighian  body  of  a  kidney,  in  the  same  hepatic  lobe 
or  brain  hemisphere. 

Small  thrombi  are  distributed  much  more  uniformly  along 
the  ramifications  of  the  main  arteries. 

LODGMENT     OF     EMBOLI — PREDISPOSITION     OF     CERTAIN 
ORGANS. 

We  have  now  reached  the  most  essential  part  of  our  sub- 
ject. Every  metastatic  affection  transmitted  by  the  blood 
vessels  groups  its  symptoms  around  the  point  where  the 
obstruction  is  lodged.  This  act  is  known  as  embolism ;  the 
plug  itself  is  called  an  embolus.  The  size  of  the  embolus 
regulates  the  distance  it  can  penetrate  into  any  given  vas- 
cular branch.  This  self-evident  proposition  is  exemplified  in 
organs  where  the  ramifications  of  the  afferent  vessels  are  less 
regular,  as  in  the  kidneys.  Here  we  may  compare  the  embo- 
lism in  the  trunk  of  the  renal  artery  with  that  of  the  arterial 
arch  on  the  borders  of  the  cortical  substance,  and  that  of  the 
ascendant  arterioles  and  the  vasa  afferentia,  and  find  that, 
with  a  similarity  of  the  general  type,  there  exists  a  very  dis- 
tinct grouping  of  individual  symptoms.  (See  text-books  on 
Pathological  Anatomy.) 

But  when  the  wandering  clot  reaches  a  certain  size,  and  its 
diameter  approaches  very  nearly  to  that  of  the  capillary 
lumina,  the  question  arises  whether  these  same  coagula  can 
pass  through  one  organ  without  hindrance  and  yet  be  detained 
in  another.  The  capillaries  are,  in  reality,  of  very  unequal 
size,  and  the  passage  from  the  arteries  to  the  capillaries,  and 
from  thence  to  the  veins,  is  in  some  organs  subject  to  so  many 
complications  that  we  can  easily  appreciate  what  is  called  the 
predisposition  of  certain  organs  to  metastatic  diseases.  We 
might  almost  assert  that  this  predisposition  stands  in  inverse 
ratio  to  the  calibre  of  a  vessel,  were  it  not  that  in  capillary 
embolism  the  consequences  of  the  obstruction  are  more 
variable  than  in  larger  arterial  obstructions,  the  immediate 
allayal  of  the  disturbance  is  much  more  frequent,  and  the  me- 
tastasis itself  less  perceptible.  Nevertheless,  the  narrowness 
of  the  brain  and  retina  capillaries  is  established  by  the  fre- 
quent presence  within  them  of  embolic  centres. 


EMBOLISM.  71 

THE    CONSEQUENCES   OF    EMBOLISM. 

The  phenomena  accompanying  the  complete  obstruction  of 
an  artery  by  an  embolus  have  been  finely  elucidated  by 
Virchow  in  his  faultless  experiments  in  comparative  anatomy, 
prefixed  to  his  studies  upon  Thrombosis  and  Embolism.  We 
now  know  that  a  perfect  embolus  only  produces  a  noteworthy 
effect  (1)  when  the  obstructed  vessel  is  an  end  artery,  i.  e., 
one  which  can  either  establish  no  anastomosis  on  the  other 
side  of  the  obstructed  channel,  or,  at  least,  one  insufficient  for 
collateral  nutrition  ;  (2)  when  the  embolus  possesses  a  chemi- 
cally or  mechanically  irritating  and  inflammatory  nature.  In 
many  cases  both  requisites  are  met  with,  as,  for  example,  in 
inetastatic  inflammations  of'the  lungs  in  pyaemia. 

We  will  now  investigate  the  mechanical  effects  of  the 
obstruction  of  an  end  artery.  Cohnheim's  experiments  on 
the  frog's  tongue  furnish  us  with  reliable  information  on  this 
point,  and  his  researches  are  none  the  less  meritorious  from 
being  a  confirmation  of  what  was  before  only  conjecture. 
The  immediate  result  of  withholding  the  blood  is,  of  course, 
an  anaemic  condition  of  the  part  in  question  (ischsemia).  The 
same  phenomena  occur  here  which  we  have  frequently  noticed 
in  all  arteries  at  death,  viz.,  as  soon  as  the  blood  pressure  is 
removed  the  powerful  contractile  tendency  of  the  artery  re- 
asserts itself,  and  the  blood  is  forcibly  driven  towards  the  large, 
relaxed  veins.  In  this  case,  the  obstructed  artery  suffers  an 
almost  total  collapse.  This  is,  however,  not  a  permanent 
condition  in  the  artery  of  the  living  body.  The  original  con- 
traction soon  relaxes,  and  presents  no  obstacle  to  the  renewed 
influx  of  blood.  Indeed,  the  blood  returns  in  superabundance, 
though  not  a  tergo,  for  in  that  direction  the  channels  are 
blocked  up,  nor  yet  through  collateral  vessels,  for  these  do 
not  exist,  but  simply  a  fronte  from  the  veins  by  way  of  the 
capillaries.  And  has  not  this  inversion  of  the  circulation  its 
complete  justification  in  the  mechanical  apparatus  ?  If  the 
blood  pressure  in  the  nearest  capillaries  is  not  great,  it  is,  at 
least,  greater  than  in  the  capillaries  of  the  ischaemic  territory. 
The  latter  must,  in  consequence,  derive  blood  from  the  former, 
until  the  resistance  of  the  overfilled  capillaries  and  the  re- 
sistance of  the  parenchyma  surrounding  the  capillaries  is 
equalized.  The  capillaries  usually  rupture,  but  generally  not 
until  the  resistance  of  the  surrounding  parenchyma  has  been 
considerably  augmented  by  the  addition  of  extravasated  blood 


72  GENERAL    PATHOLOGY. 

serum.  Thus  the  parenchyma  does  not  always  receive  an 
influx  of  pure  blood, — a  hemorrhagic  infarct,  as  it  is  called, — 
but  often  becomes  filled  with  a  sanious  transudation  or  an 
imperfect  infarction. 

The  appearance  of  engorgement  of  blood  and  hemorrhage 
in  detached  cases  is  of  no  essential  value.  One  factor  is,  how- 
ever, invariable.  The  blood  does  not  flow  on  in  the  dilated 
vessels,  it  stagnates  and  imparts  a  fatal  lethargy  to  the  metas- 
tatic  centres.  Gangrene  and  decomposition,  the  fatal  pre- 
cursors of  local  death,  soon  set  in,  accompanied  by  an  offensive 
odor. 

So  much  for  the  direct  mechanical  results  of  the  embolus  of 
an  end  artery.  The  succeeding  stages  are  to  be  regarded  in 
the  main  as  "the  reaction  of  the  healthy  surrounding  tissue 
with  its  free  circulation  against  the  enclosed  dead  area.  The 
latter  sends  out  the  products  of  decomposition  in  all  direc- 
tions, and  the  strongly  irritating  composition  of  these  products 
occasion  an  acute  suppurative  inflammation,  called  a  inetastatic 
inflammation  or  metastatic  abscess. 

The  detailed  account  of  the  inflammatory  phases  is  reserved 
for  special  chapters  on  pathological  anatomy.  But  let  us 
remember  that  the  hemorrhagic  infarct  and  its  accompanying 
results  are  not  the  sole  and  inevitable  effects  of  an  arterial 
obstruction.  If  the  obstruction  be  located  in  the  main  artery 
of  the  lung,  the  consequence  is  immediate  death  by  suffoca- 
tion ;  if  in  the  main  artery  of  the  kidney,  it  produces  necrosis 
of  the  entire  kidney,  which  is  not  initiated  by  an  overloading 
of  the  blood  vessels,  and  which  converts  the  organ,  without 
offensive  decay,  into  a  yellowish,  doughy,  anaemic  mass,  which 
suffers  a  tedious  process  of  maceration  and  re-absorption. 

If  the  embolus  is  so  constituted  that,  by  reason  of  its 
chemical  qualities  as  a  partially  decomposed  body,  it  involves 
the  neighboring  tissues  in  suppurative  inflammation,  it  is  natur- 
ally of  less  importance  whether  the  obstructed  vessel  is  or  is 
not  an  end  artery.  The  final  result  of  a  metastatic  abscess 
will  be  the  same  in  both  cases. 


FEVER.  73 

FEVER. 

Any  noticeable  and  prolonged  increase  in  the  natural  heat 
of  the  body,  not  due  to  external  agencies,  is  called  Fever.  In 
fever,  the  body  produces  an  amount  of  heat  somewhat  in 
excess  of  the  amount  it  throws  off,  although  it  is  not  only 
a  priori  probable,  but  demonstrably  true,  that  the  escape  of 
heat  is  augmented  in  febrile  affections. 

The  cardinal  symptom  of  fever  is  the  elevation  of  the  bodily 
temperature.  The  concomitants  of  fever  heat  are :  increased 
frequency  of  the  pulse  and  respiration  ;  disturbances  of  the 
temperature,  nerves  and  muscles;  indigestion;  diminished 
secretion  of  urine,  etc.  Some  of  these  symptoms  may  be  pro- 
duced by  an  artificial  elevation  of  temperature  (experiments 
on  animals  in  hot-air  ovens).  This  fact  might  lead  one  to 
infer  that  all  other  fever  symptoms  are  the  result  of  fever 
heat.  But  as  only  a  few  of  these  symptoms  can  be  produced 
by  artificial  means,  and  then  incompletely,  it  will  be  safe  to 
regard  them  as  proceeding  from  the  general  cause  of  fever. 

CAUSE  OF    FEVER. 

The  chief  cause  of  fever  is  now  held  by  most  writers  to  be 
the  introduction  into  the  blood  of  certain  substances  which 
augment  combustion,  and  hence  are  called  pyrogenous  sub- 
stances. Some  of  these  substances  are  generated  in  inflam- 
matory centres,  whence  they  are  absorbed  by  the  lymphatics  ; 
others  are  introduced  into  the  body  from  without,  like  the 
inhaled  poison  of  infectious  diseases.  The  pyrogenous  matter 
acts  as  a  ferment  upon  the  albumen  of  the  body,  disintegrates 
its  molecules,  and  renders  it  susceptible  to  oxygenation.  The 
result  of  this  activity  is  soon  recognized  in  the  increased 
excretion  of  the  products  of  disintegration.  Twice  the  normal 
quantity  of  urea  is  produced,  and  two-and-a-half  times  the 
normal  quantity  of  nitrogen. 

The  "  nervous  "  theory  of  fever,  as  it  is  called,  maintains 
that  the  heightened  oxidation  in  fever  may  be  accomplished 
otherwise  than  by  the  above-described  fermentation  or 
"  zymosis."  This  theory  supposes  that  the  presence  of  pyro- 
genous matter  in  the  blood  would  react  upon  the  central 
nervous  system  in  such  a  manner  as  to  excite  muscular  com- 
bustion, and  thus  elevate  the  bodily  temperature.  According 
to  this  view,  fever  heat  is  not  produced  directly,  but  by  the 
6 


74  GENERAL   PATHOLOGY. 

agency  of  the  nervous  system.  Whether  it  can  be  produced 
in  any  other  way  than  by  the  increase  of  oxidation  will  be 
considered  under  the  head  of  disturbances  of  temperature, 
where  we  will  also  discuss  Traube's  fever  theory. 

FEVER  HEAT. 

In  order  to  correctly  apprehend  the  value  of  thermometrical 
estimates  of  bodily  temperature,  we  must  bear  in  miud  that 
the  body  of  the  fever  patient  resembles,  to  a  certain  degree, 
any  other  body  whose  temperature  exceeds  the  surrounding 
medium.  As  it  is  constantly  giving  off  a  portion  of  its  specific 
warmth,  its  peripheral  temperature  is  lower  than  that  of  its 
centre.  We  need  not  be  surprised,  therefore,  if  the  tempera- 
ture taken  in  the  axilla  is  0.8-1.1°  C.  (1.44°-2°  F.)  lower  than 
that  taken  in  the  vagina  or  rectum.  The  circulation  of  the 
blood  is  admirably  fitted  to  regulate  such  inequalities  of  bodily 
temperature,  but  the  influence  of  the  external  cold  extends 
to  such  a  depth  that  the  uniform  internal  heat  can  only  be 
ascertained  by  inserting  the  thermometer  some  distance  into 
the  rectum.  The  temperature  of  the  mouth  is  midway  be- 
tween that  of  the  rectum  and  axilla. 

The  average  normal  temperature  of  the  body  is  as 
follows  :— 

Axilla.  Beclum. 

In  adults,      36.2°  to  37.4°  0.  (97.2°  to  99.3°  F.)    36.8°  to  38°     C.  (98  2°  to  100.4°  F.) 
In  children,  36.4°  to  37,7°  C.  (97.5°  to  99.8°  F.)    37.0°  to  38.2°  C.  (98.6°  to  100.7°  F.) 

The  fluctuations  in  these  figures  arise,  in  part,  from  indi- 
vidual peculiarities,  in  part,  from  the  time  of  day  when  they 
were  taken.  The  average  daily  fluctuation  in  the  tempera- 
ture of  an  individual  is  one  degree  Celsius  (1.8°  F.)  The  tem- 
perature is  lowest  between  1  and  2  A.  M.  Toward  morning, 
especially  after  waking,  it  rises,  and,  under  the  influence  of 
physical  exertion  and  the  reception  of  food,  increases  until 
noon  ;  just  before  aoon  there  is  a  slight  fall,  but  at  5  P.M.  the 
maximum  is  reached.  The  fall  of  the  temperature  is  appar- 
ently favored  by  the  inactivity  of  the  muscles  during  sleep, 
so  that  the  minimum  is  reached  about  midnight. 

We  might  be  led  to  infer,  from  the  above,  that  the  daily 
fluctuations  were  caused  exclusively  by  muscular  activity  and. 
the  reception  of  food.  This  must,  however,  be  accepted  cum 
grano  satis.  Muscular  activity  and  the  consumption  of  food 
are  undoubtedly  factors  which  now,  as  always,  encourage  and 


FEVER.  75 

foster  the  daily  fluctuation.  But  a  daily  fluctuation  neverthe- 
less exists,  independently  of  these  agencies,  appearing  in  the 
total  absence  of  muscular  activity  and  reception  of  food. 

In  fever,  the  bodily  temperature  is  very  soon  raised  1°  C. 
(1.8°  F.) ;  3°  C.  (5.8°  F.)  above  this  is  the  average  maxi- 
mum reached  in  ordinary  fevers.  A  temperature  above 
41.5  C.  (106.7°  F.)  (in  the  axilla)  very  rarely  occurs,  and 
threatens  a  fatal  termination  of  the  disease.  Yet  recovery 
has  followed  a  temperature  of  42.5  C.  (108.5°  F.) 

Fever  temperature  is,  in  the  main,  much  less  uniform  than 
the  normal.  It  undergoes  a  series  of  typical  changes,  which 
must  be  carefully  noted  in  individual  diagnosis.  The  daily 
fluctuation  is  also  important  in  fever  cases.  The  daily  rise 
(exacerbation)  begins  a  little  later  than  in  health,  viz.,  about 
9  A.  M.,  and  the  acme  (fastigium)  is  attained  in  the  afternoon. 
After  this,  it  continues  uniform  for  several  consecutive  hours, 
and  does  not  begin  to  decline  (remission)  until  about  8  P.  M. 
The  minimum  is  frequently  not  reached  until  toward  morning. 

In  slight  fevers,  such,  for  instance,  as  accompany  simple 
mucous  catarrhs,  the  daily  fluctuation  is  1-1  J°  C.  (1.8-2.7°  P.), 
the  minimum  being  38°  C.  (100.4°  F.),  the  maximum  39.5°  C. 
(103.1°  F.)  Severe  fevers  are  distinguished,  not  only  by 
higher  elevations  of  temperature,  but  also  by  strong  remis- 
sions. Fevers  with  slight  daily  fluctuations,  where  the  fever 
heat  fluctuates  above  39°  C.  (102.2°  F.),  (febres  continual), 
are  found  in  typhoid  fever,  and  other  serious  infectious 
maladies.  Fevers  with  marked  daily  fluctuations,  3°  C. 
(5.4°  F.),  are  called  remittent,  and  are  characteristic  of 
certain  severe  diseases.  In  malarial  fevers,  we  have  half-day 
paroxysms  of  fever,  which  alternate  with  periods  of  normal 
temperature  (apyrexia).  When  these  intermissions  are  of  a 
half  day's  duration,  the  fever  is  called  quotidian ;  when  of 
one  and  a  half  day's,  it  is  called  tertian ;  when  of  two  and  a 
half,  quartan.  Such  fevers  are  called  intermittent. 

Every  fever  presents  in  its  entirety  a  series  of  changes  ;  it 
has  a  rise,  an  acme,  and  a  fall.  The  rapidity  with  which  the 
rise  and  subsequent  fall  are  effected  varies  widely  in  different 
diseases,  and  is,  therefore,  an  important  diagnostic  symptom. 
A  rapid  and  complete  subsidence  of  fever  is  called  a  crisis. 
This  crisis  usually  betokens  that  the  system  has  gained  the 
victory  over  the  pyrogenous  substances  (the  "  materies 
peccans  "  of  our  ancestors),  has  either  rejected  or  consumed 


76  GENERAL   PATHOLOGY. 

them,  and  fortified  itself  against  further  inroads.  The  crisis 
is,  accordingly,  a  process  of  nature,  not  of  disease.  It  is  apt 
to  occur  at  stated  intervals.  The  fourth,  seventh,  eleventh, 
fourteenth,  seventeenth  and  twentieth  days  of  the  month  have 
been  the  traditional  critical  days,  a  tradition  which  has  often 
been  verified  by  fact.  The  gradual  subsidence  of  fever  is 
called  lysis. 

There  are  also  many  minor  fluctuations  of  fever  heat,  such 
as  a  "  step-like"  ascent  and  "  terrace-like"  descent,  which  are 
readily  perceived  by  taking  the  temperature  at  intervals  of 
five  minutes,  and  noting  the  result  on  the  temperature  sheet. 
It  seems  most  plausible  to  refer  minor  fluctuations  to  the 
irregular  periodicity  in  the  activity  of  the  heat-regulation 
apparatus, — a  subject  we  will  proceed  to  consider  more  at 
length. 

DISTURBANCES  IN   THE   HEAT-REGULATING   APPARATUS. 

It  is  self-apparent  that  an  abnormal  elevation  of  the  normal 
temperature  affects  first  of  all  that  apparatus  whose  function  it 
is  to  regulate  the  escape  of  heat,  and  to  maintain  an  average 
temperature  37.5°  C.  (99.5°  F.)  A  large  number  of  fever  symp- 
toms must  be  regarded  in  this  light,  i.  e.,  as  a  reaction  of  the 
heat-regulating  apparatus  upon  the  elevated  bodily  tempera- 
ture. First  in  importance  among  the  symptoms  is  the  chill,  with 
which  most  severe  fevers  begin,  and  which  frequently  recurs  in 
later  exacerbations.  A  strong  subjective  sensation  of  cold  is 
accompanied  by  shivering,  paleness  of  the  skin,  shaking  and 
trembling  of  the  whole  body,  knocking  together  of  the  limbs, 
and  chattering  of  the  teeth.  All  the  muscular  fibres  con- 
tained in  the  outer  skin  contract.  By  the  contraction  of  the 
erector  pill  the  hair  follicle  is  raised,  causing  the  so-called 
goose  skin.  Still  more  important  is  the  contraction  of  the 
capillaries,  in  consequence  of  which  little  blood  circulates 
through  the  skin,  and  the  escape  of  bodily  heat  is  thereby 
greatly  lessened.  We  meet  here  one  of  the  most  striking 
paradoxes  in  the  action  of  the  heat-regulating  apparatus. 
We  are  prepared  to  see  an  elevation  of  bodily  temperature 
followed  by  a  corresponding  opening  of  the  ventilative  appa- 
ratus, a  dilatation  of  the  capillaries,  secretion  of  sweat,  etc. 
Exactly  the  opposite  takes  place,  and  we  are  tempted  to 
regard  the  mechanism  of  the  heat-regulating  apparatus  as  a 
highly  inadequate  one.  As  it  is  now  established  beyond 


FEVER.  77 

doubt  that  a  chill  increases  considerably  the  bodily  tempera- 
ture, we  can  understand  how  Traube,  an  accomplished  path- 
ologist, attempted  to  prove  that  the  elevation  of  temperature 
in  fever  was  due  to  this  cause  alone. 

Liebermeister  has  tried  to  explain  this  paradoxical  appear- 
ance by  saying :  In  every  fever  there  exists  a  standard  of 
heat-regulation  higher  than  that  of  the  normal  mechanism, 
regulating  the  production  as  well  as  the  escape  of  bodily  heat. 
As  the  healthy  body  is  regulated  for  37.5°  C.  (99.5°  F.),  so 
in  fever,  it  is  regulated  for  39°  or  40°  C.  (102.2°  or  104°  F.) 
Employing  the  same  means  as  those  at  work  in  a  healthy 
man,  the  production  of  heat  is  increased,  and  the  escape 
prevented  by  the  contraction  of  the  capillaries. 

To  accept  heat-regulation  as  a  changing  apparatus  possesses 
such  a  fascination  for  the  spirit  of  the  nineteenth  century  that 
it  is  with  reluctance  that  I  advance  contrary  views.  I  believe 
in  the  physiological  basis,  but  do  not  think  that  such  a  clever 
hypothesis  can  be  maintained.  When  the  temperature  of 
our  blood  begins  to  rise  as  the  result  of  external  heat,  we  en- 
deavor, by  discarding  our  extra  clothing,  to  reduce  our  tem- 
perature to  normal  again.  But  is  it  really  the  perception  of 
increasing  bodily  heat  which  makes  us  do  this?  Is  it  not 
rather  the  sensation  of  an  insufficient  escape  of  heat,  the 
feeling  that  we  cannot  get  rid  of  our  warmth,  that  our  skin  is 
overheated  ?  On  the  other  hand,  when  a  sudden  fall  of 
external  temperature  causes  us  to  button  up  our  coats  and 
draw  on  our  gloves,  every  one  feels,  undoubtedly,  that  it  is 
done  in  order  to  prevent  the  too  great  escape  of  warmth.  The 
"  perception  of  an  increased  or  diminished  escape  of  warmth" 
incites  the  heat-regulating  apparatus  to  a  corresponding 
activity. 

Our  own  arbitrary  standard  concerning  the  heat-regulating 
apparatus  is  fixed  by  the  rapidity  with  which  our  body  is 
cooled  off  externally, — best  seen  in  the  sudden  effect  of  warm 
or  cold,  local  or  general  baths.  This  arrangement  has  more 
than  one  disadvantage.  It  would  certainly  have  been  much 
better  for  a  frozen  finger  or  toe,  had  its  blood  vessels  dilated 
and  allowed  warm  blood  to  flow,  instead  of  remaining  con- 
tracted. But  the  rules  of  this  regulating  apparatus  are  such 
that  when  a  powerful  external  escape  of  heat  begins,  the 
capillaries  contract,  while  they  open  on  the  other  hand  when 
there  is  little  or  no  escape. 


78  GENERAL   PATHOLOGY. 


know  beyond  doubt  that  when  our  bodily  temperature 
ed  by  fever,  the  external  escape  of  warmth  is  increased, 


We 

is  roused 

the  surrounding  air  feels  cold  to  the  fever  patient,  he  seeks  a 
warm  bed  in  order  to  put  an  end  to  this  excessive  loss  of 
bodily  heat.  The  heat  regulating  apparatus  is  plainly  in  accord 
with  the  patient,  for  the  capillaries  contract,  the  erectores 
pilorum  form  goose-skin,  the  teeth  chatter,  and  the  patient  has 
a  chill.  I  consider  a  chill  to  be  nothing  more  than  an  erroneous 
interpretation  of  the  unquestionably  increased  escape  through 
the  skin  of  bodily  heat,  augmented  by  the  high  temperature 
of  the  blood  of  the  fever  patient.  The  heat-regulating  appa- 
ratus fluctuates  hither  and  thither,  uncertain  whether  to  lower 
the  bodily  temperature  by  opening  up  the  radiating  apparatus 
of  the  skin,  or  to  prevent  the  escape  of  warmth  by  contract- 
ing the  capillaries.  This  indecision  often  lasts  for  some  time. 
As  an  example  of  this  vacillation  in  an  apparatus  otherwise 
so  complete,  we  might  mention  the  sudden  shiver  produced  by 
a  slight  breeze  in  a  patient  whose  skin  is  burning  with  fever. 

Whatever  may  be  the  thermal  effect  of  a  chill,  there  is  no 
doubt  that  it  preserves  warmth,  and  that  the  previous  tempera- 
ture of  the  blood  is  increased.  But  since  in  fever,  the  loss  of 
heat,  in  spite  of  the  preservation  of  warmth,  is  greater  than 
in  health,  the  preservation  of  heat  by  a  chill  cannot  be 
regarded  as  the  sole  cause  of  fever,  but  only  as  a  secondary 
factor  of  the  same.  As  before  remarked,  the  gradation 
which  is  found  by  minutely  observing  the  daily  rise  and  fall 
of  fever,  is  to  be  attributed  to  the  vacillation  of  the  heat-regu- 
lating apparatus. 

Again,  we  must  not  forget  that  chills  and  ague  fits  are  only 
temporary  phenomena,  and  that  they  alternate  with  that 
totally  different  condition  of  the  heat-regulating  apparatus, 
in  which,  by  dilatation  of  the  capillaries,  the  abnormal  loss  of 
heat  is  still  further  increased.  The  over-irritation  of  the 
capillaries  is  followed  by  a  relaxation  of  their  muscular  walls, 
which  often  lasts  for  some  time.  This  is  associated  with 
a  sensation  of  heat  which  often  becomes  almost  unbearable, 
because  the  nerve  filaments  in  the  skin  now  record  this 
elevation  of  temperature, — an  office  which  they  are  only 
called  upon  to  fill  when  the  external  temperature  has  far 
exceeded  that  of  the  blood. 

During  the  entire  rise  and  acme  of  a  fever,  this  same 
fluctuation  of  the  heat-regulating  apparatus  continues.  When 


FEVER.  79 

the  crisis  approaches,  we  often  find  hypersemia  of  the  skin, 
together  with  profuse  perspiration.  Under  the  double 
influence  of  increased  radiation  and  evaporation,  defervescence 
sets  in,  the  temperature  in  the  meantime  falling  to  normal,  or 
occasionally,  below. 

DERANGEMENTS  IN  THE  CIRCULATORY  APPARATUS  IN  FEVER. 

Before  the  introduction  of  the  use  of  the  thermometer  in 
medicine,  the  counting  of  the  pulse  and  the  valuation  of  the 
same  were  the  most  reliable  means  of  diagnosing  an  existing 
fever.  Even  to-day  the  accelerated  pulse  may  be  regarded  as 
an  almost  constant  symptom  of  fever.  With  the  rise  of  one 
degree  in  temperature,  we  may  expect  an  increase  of  eight 
beats  in  the  pulse,  though  cases  in  which  the  pulse  increases 
twenty  beats  per  minute  are  frequently  found,  and  a  pulse- 
rate  of  120  has  been  observed  in  adults,  and  one  of  140-160 
in  children. 

It  is  not  only  from  the  number,  however,  but  also  from  the 
quality  of  the  beats,  that  the  physician  draws  his  inference. 
In  this  respect  we  must  expect  that  the  accelerated  heart- 
beats, cceteris  paribus,  will  cause  a  rise  of  arterial  pressure. 
This  is  best  seen  in  the  hard  pulse.  Here  the  pulse  feels  like 
a  cord,  and  gives  to  the  finger  a  short,  powerful  beat.  The 
hard  pulse  (pulsus  durus)  is  often  found  in  the  beginning  of 
a  fever.  If  the  latter  has  lasted  for  some  time,  the  hardness 
of  the  artery  gives  way,  and  the  pulse-wave,  although  "full," 
gives  us  a  weak,  elastic  impression  (pulsus  amplus).  The 
difference  between  a  hard  and  full  pulse  does  not  depend  upon 
a  different  variety  of  heart  contractions,  but  upon  the  action 
of  the  coats  of  the  various  arteries.  So  long  as  the  hard 
pulse  continues,  the  arteries  are  excited  to  contract ;  in  a 
weak,  full  pulse,  this  excitement  has  abated,  and  a  certain 
relaxation  has  set  in.  By  this  relaxation,  this  general  lack 
of  arterial  tonus,  the  arterial  pressure  is  somewhat  lowered,  so 
that  the  systolic  pulse  appears  unusually  strong  by  contrast, 
and  the  arteries  very  full. 

In  the  pulsus  amplus  the  dicrotism  of  the  pulse  is  especially 
well-marked,  because  a  relaxed  arterial  wall  transmits  this 
disputed  secondary  wave  better  than  a  tense  wall.  Both  the 
hard  and  the  full  pulse  presuppose  a  faultless  action  of  the 
heart,  the  ventricles  being  filled  to  their  fullest  extent  during 
diastole,  and  powerfully  and  completely  emptied  during  systole. 


80  GENERAL   PATHOLOGY. 

The  condition  of  the  heart  in  protracted  fevers  may  be 
compared  to  that  of  a  horse,  which,  from  overwork  and  insuf- 
ficient feeding,  becomes  tired,  weak,  and  emaciated.  Diges- 
tion fails,  and  with  it  the  transmission  of  new  nutritive 
material  to  the  blood,  while  the  process  of  oxidation  is  at  the 
same  time  increased.  Thus  the  quality  of  the  blood  deterior- 
ates ;  the  food  of  the  heart  is  less  nutritious  than  formerly. 
Add  to  this  the  excessive  increase  of  the  work  of  the  heart, 
and  we  can  easily  see  how  the  organ  loses  its  irritability, 
becomes  weak,  and  contracts  only  feebly.  It  is  also  possible 
that  the  rise  of  temperature  exerts  a  deleterious  influence  upon 
the  action  of  the  heart,  and  it  is  by  no  means  certain  that  the 
cause  of  fever  does  not  act  as  a  heart  poison. 

The  direct  consequence  of  the  heart  having  more  work 
to  do  than  it  can  accomplish,  is  a  decrease  in  arterial  pressure 
and  in  the  rapidity  of  the  blood.  The  pulse  can  scarcely  be 
felt,  it  is  weak  and  easily  compressed,  and  beats  with  an 
added  rapidity,  as  if  the  heart  wished  to  make  up  in  speed 
what  it  has  lost  in  force  (  pulsus  frequens). 

Finally,  even  this  correction  fails.  The  scarcely  percep- 
tible beats  of  the  small  pulse  (pulsus  parvus),  which  frequently 
cannot  be  counted,  are  no  longer  able  to  prevent  the  threat- 
ened fall  of  arterial  pressure  and  the  stoppage  of  the  circula- 
tion. In  cases  of  this  sort,  it  is  not  rare  to  find  a  fatty 
degeneration  of  the  relaxed  flaccid  heart  muscle,  which  is  a 
palpable  symptom  of  the  disturbances  of  nutrition  which  have 
taken  place. 

It  is  more  than  probable  that  the  rise  in  the  frequency 
of  the  pulse  is  dependent  upon  the  cardinal  symptom  of  fever 
— fever  heat.  This  increased  pulse,  as  well  as  the  increased 
respiration,  is  found  in  cases  where  the  blood  temperature  has 
been  raised  a  few  degrees  by  external  warmth.  This  is, 
doubtless,  effected  through  the  agency  of  the  nervous  system, 
although  the  nervous  influence  is  more  marked  upon  the 
respiration  than  upon  the  heart. 

FEBRILE     DISTURBANCES   IN    THE    ORGANS   WHICH    PRODUCE 
AND   PURIFY   THE   BLOOD. 

Among  the  vegetative  functions,  disturbances  of  digestion  are 
first  of  all  apparent.  Loss  of  appetite,  nausea  and  vomiting, 
together  with  marked  desquamative  catarrh  of  the  tongue 
(coated  tongue),  denote  an  anomalous  condition  of  the  mucous 


FEVER.  81 

membrane  of  the  stomach,  which  is  generally  considered  to  be 
a  slight  catarrhal  or  parenchymatous  (glandular)  inflamma- 
tion. The  ordinary  results  are  a  complete  abstinence  from 
food,  and  a  suspension  of  activity  in  the  processes  of  digestion 
and  resorption  in  the  stomach  and  organs  below  it,  which 
do  not  resume  their  normal  activity  for  days  or  even  weeks. 
Nutrition  is  thus  cut  off  and  destroyed  in  its  first  and  earliest 
stages.  The  body  rapidly  loses  in  weight,  on  account  of  the 
increased  combustion  of  oxidiz&ble  substances  in  the  blood 
and  tissue,  its  fat  disappears,  and  its  muscles  waste  away 
(consumptio  febrilis). 

These  changes  manifest  themselves  in  the  constantly 
increasing  amount  of  urea  thrown  off  by  the  kidneys,  and  of 
nitrogen  by  the  lungs.  Less  urine  is  voided  in  fever  than  in 
health,  but  it  is  very  concentrated,  dark  in  color,  and  contains 
in  proportion  one-third  more  urea  than  normal  urine.  Uric 
acid  is  also  increased,  and  when  the  urine  is  cold,  it  deposits 
itself  in  the  shape  of  sodium  urate  (sedimentum  lateritium}. 
Phosphoric  acid  is  also  increased ;  in  short,  all  the  well- 
known  products  of  oxidation  of  albuminoid  substances  which 
we  find  in  urine  are  increased. 

In  a  similar  manner  the  function  of  the  lung  deviates  from 
normal.  A  positive  increase  in  the  elimination  of  nitrogen 
occurs  in  fevers,  where,  with  elevated  temperature  and  pulse, 
the  respirations  increase  ten  or  twenty  per  minute.  This 
elimination  increases  at  first  at  a  uniform  rate  with  the  tem- 
perature, but  presently  reaches  its  maximum,  from  which  it 
soon  descends,  occupying  a  slightly  higher  level  than 
formerly. 

As  regards  the  skin,  the  loss  of  moisture  by  insensible  per- 
spiration is  increased  under  all  conditions  as  the  skin  becomes 
warmer.  The  sensible  perspiration  is  commonly  diminished 
during  a  fever,  but  appears  readily  as  a  critical  phenomenon, 
in  the  shape  of  profuse  sweat,  as  soon  as  defervescence  has 
distinctly  set  in. 

FEBRILE   DISTURBANCES    OF    THE    NERVOUS    SYSTEM. 

The  central  nervous  system  is  especially  susceptible  to  all 
abnormal  deviations  in  the  consistency  of  the  blood.  Nearly 
all  dyscrasias,  i.  e.,  pathological  accumulations  in  the  blood  of 
excretory  products,  as  well  as  the  addition  of  foreign,  poisonous, 
infectious  substances,  cause  a  general  irritation  of  the  brain 


82  GENERAL   PATHOLOGY. 

and  spinal  cord,  whose  typical  phenomena  we  will  now 
study.  In  fevers,  this  general  irritation  shows  itself  in  head- 
ache, extreme  impressibility  of  the  senses,  hallucinations,  and 
delirium,  alternating  with  lassitude,  weariness  and  drowsiness, 
to  which  is  added  the  perception  of  perverted  activity  on 
the  part  of  the  heat-regulating  apparatus,  as  an  indescribably 
peculiar  sensation  in  the  external  layer  of  the  outer  skin. 

Our  first  idea  would  naturally  be  to  regard  the  increased 
temperature  of  the  blood  as  the  immediate  cause  of  this  im- 
plication of  the  central  nervous  system.  But  we  must  not 
jump  at  conclusions.  Generally,  indeed,  a  febrile  rise  of 
temperature  appears  attributable  to  impure  blood,  so  that  we 
cannot  state  how  much  of  this  general  irritation  of  the  nervous 
system  is  due  directly  to  this  impurity,  and  how  much  to  the 
elevation  of  temperature.  Indeed,  the  occurrence  of  fever, 
without  any  perceptible  blood  changes,  would  denote  that  the 
elevation  of  temperature  can  arise  by  nervous  means,  and 
points  to  the  so-called  "  nervous  theories  "  of  fever.  It  is  a 
well-known  fact  that  many  of  our  fever  remedies  are  at  the 
same  time  nervines.  I  must,  however,  refrain  to  enter  here 
into  the  further  consideration  of  the  question. 

CACHEXIA. 

There  are  many  terms  in  the  medical  vocabulary  to  express 
a  weak  and  depraved  condition  of  the  system,  viz.,  decrepitude, 
marasmus,  cachexia,  consumption,  etc.  Each  is  supposed  to 
describe  the  origin  of  the  particular  trouble.  Of  febrile  con- 
sumption we  have  already  spoken.  Cachexia  proper  is  that 
condition  of  defective  quality  and  quantity  of  the  blood 
brought  about  by  long  continued  suppuration  and  pathologi- 
cal new  formation.  This  deterioration  is  due  partly  to  the 
appropriation  of  the  constructive  material  by  the  massed 
or  detached  pathological  cells,  partly  to  the  introduction 
into  the  blood  of  fermentative  matter  from  the  centres  of 
inflammation  and  new-formation.  We  have  seen  (page  56) 
how  cancerous  cachexia  arises  in  malignant  tumors ;  in 
like  manner  arise  the  numerous  cachectic  conditions  pro- 
duced by  the  tedious  processes  of  specific  inflammation  and 
suppuration.  With  these  cachexias  there  is  often  associated  a 
peculiar  consequent  change  in  the  various  organs  of  the  body, 
which,  on  account  of  its  importance,  will  form  the  theme  of 
our  next  division. 


CACHEXIA.  83 

AMYLOID   DEGENERATION. 

Amyloid  degeneration  is  the  infiltration  of  certain  cells  and 
tissues  with  a  firm  albuminous  body,  to  which,  on  account 
of  its  present  behavior  toward  iodine,  the  term  "  starch-like  " 
was  applied  by  its  discoverer.  If  a  fresh  section  of  an  organ 
in  a  condition  of  amyloid  degeneration  be  washed  in  water,  to 
remove  the  blood,  a  weak  solution  of  iodine  poured  over  it, 
the  infiltrated  spots  will  assume  the  reddish-brown  color  of 
old  mahogany.  Sulphuric  acid  added  to  this  will  produce  a 
deeper  color,  shading  into  blue  and  violet,  though  the  latter 
tints  are  soon  lost  in  the  subsequent  charring  process. 

That  the  "  amyloid  substance  "  is  not  reparative,  but  is  an 
albuminous  body  chemically  allied  to  fibrin,  has  long  been 
known.  By  studying  the  process  of  amyloid  infiltration  as  far 
as  possible,  under  the  microscope,  we  shall  see  a  substance  which 
appears  to  be  lodged  in  the  interstices  of  the  protoplasmic 
granules  of  a  cell,  or  between  the  most  minute  fibrillse  of  the 
connective  tissue.  The  refractive  power  of  this  body  is  suffici- 
ently strong  to  equalize  all  optical  differences,  so  that  the  cells 
and  fibres  appear  after  infiltration  entirely  homogeneous  and 
wax-like  and  are  also,  through  the  added  substance  somewhat 
larger  and  more  rounded  off,  suggesting,  as  C.  O.  Weber  says, 
"  a  glassy  swelling."  There  is  also  an  unmistakable  tendency 
towards  aggregation.  The  process  resembles,  in  some  respects, 
that  of  coagulation-necrosis  (page  31,  a./.),  with  this  difference, 
that,  although  it  is  difficult  to  form  an  exact  estimate  of  the 
vital  activity  of  the  degenerated  part,  it  is,  at  least,  sufficient 
to  preserve  the  part  alive,  and  it  rarely  happens  that  an  organ 
becomes  so  completely  degenerated  by  amyloid  change  that  it 
is  treated  by  the  system  as  "  dead,"  i.  e.,  thrown  off  by 
suppuration,  which  is  the  case  in  coagulation-necrosis. 

The  very  marked  peculiarity  of  amyloid  degeneration 
leads  us  to  infer  special  conditions  in  its  manner  of  origin. 
The  chief  of  these  is  the  extreme  impoverishment  in  the 
solid,  i.  e.,  cellular  constituents  of  the  blood.  In  all  cases 
of  amyloid  degeneration  of  organs,  the  blood  is  reduced  to 
one-half  the  average  amount,  and  sometimes  even  less.  It  is 
of  a  thin  consistency  and  very  bright  in  color.  If  allowed  to 
stand,  the  fluid  becomes  clear  on  top  and  deposits  a  thin  layer 
of  blood  corpuscles  on  the  bottom  of  the  glass.  This  deposit 
is  scarcely  more  than  the  twentieth  part  of  the  entire  height, 
and  is  composed  almost  entirely  of  red  cells.  After  some 


84  GENERAL   PATHOLOGY. 

time  the  fluid  on  top  coagulates  into  a  tough  buffy  coat, 
(Brady-fibrin).  If  a  few  drops  of  fresh  healthy  blood  be  added, 
the  coagulation  is  instantaneous. 

We  see  that  the  blood  has  undergone  decided  changes. 
There  is  a  lack  of  cells,  and  the  fibrin  generators  are  not  in 
the  right  proportion.  The  chief  causes  of  this  depraved  con- 
dition are  suppurating  diseases,  especially  those  in  which  an 
excessive  loss  of  white  blood  corpuscles  occurs,  and  in  tuber- 
culous and  syphilitic  suppurations  in  the  osseous  and  pulmon- 
ary systems. 

The  degeneration  usually  begins  in  several  places  simulta- 
neously, though  the  preference  is  given  to  those  where  the  blood 
remains  longest,  and  there  is  a  stronger  transudation  of  blood- 
serum,  as  in  the  liver,  spleen,  kidneys,  etc.;  the  lymphatics 
and  the  thyroid  gland  are  attacked  later.  The  capillary  walls 
are  first  infiltrated,  a  process  best  observed  in  the  kidneys. 
The  next  point  of  attack  is  the  connective  tissue,  and  then  the 
parenchyma  cells  of  organs.  Amyloid  degeneration  of  single 
cells  may  be  finely  studied  in  the  liver  cells,  as  well  as  in 
those  of  the  lymphatic  glands. 

To  sum  up :  the  albumen  of  the  transuding  nutritive  fluid 
appears  to  be  arrested  in  the  tissues  through  which  it  must 
pass,  i.  e.,  secreted  in  a  solid  form  by  a  process  greatly  resemb- 
ling the  coagulation  of  fibrin. 

IRRITATION  OF  THE  NERVOUS  SYSTEM. 

It  is  well  known  that  in  every  serious  disease  the  nervous 
system  becomes  involved.  This  is  accomplished  by  a  double 
process.  First,  the  central  nervous  system  being  excessively 
sensitive  to  an  abnormal  composition  of  the  blood,  reacts 
against  it  by  periods  of  abnormal  excitation,  alternating  with 
corresponding  periods  of  lassitude  and  exhaustion.  Second, 
the  local  irritation  of  a  nerve  is  transmitted  to  the  central 
organ  where  very  disproportionate  results  are  at  times  pro- 
duced. 

Before  entering  upon  the  consideration  of  those  symptoms 
which  characterize  both  general  and  local  irritation,  particular 
mention  must  be  made  of  two  phenomena  peculiar  to  all 
symptoms  proceeding  from  the  nervous  system.  These  phe- 
nomena, which  have  already  been  briefly  touched  upon,  are  : 
the  more  or  less  decided  periodicity  of  nervous  attacks,  and 
the- frequent  disproportion  in  them  between  cause  and  effect. 


IRRITATION   OF   THE   NERVOUS   SYSTEM.  85 

The  first,  periodicity,  is  the  outcome  of  a  great  biological 
law,  by  which  all  sensitive  vital  substances  are  forced  to 
alternate  between  rest  and  activity,  and  to  this  alternation 
the  process  of  assimilation  is  cleverly  adapted.  In  the  nervous 
system,  however,  where  this  sensibility  of  the  organism  finds 
its  most  intense  expression,  the  alternation  of  activity  and 
recuperation  is  most  marked,  and  the  two  phases  most  antipo- 
dal. The  relative  difference  between  the  abnormal  processes 
of  excitation  and  exhaustion  may  be  observed  in  the  difference 
between  the  normal  conditions  of  sleeping  and  waking. 

The  second  peculiarity  of  nervous  symptoms,  the  dispro- 
portion between  cause  and  effect,  arises  from  the  power  of  the 
central  nervous  system  to  imperceptibly  gather  up  enormous 
numbers  of  centripetal  irritations,  and  preserve  them  in  the 
shape  of  tension.  Thus  it  sometimes  happens  that  an  attack 
is  made  upon  the  nervous  system,  which,  though  in  itself, 
hardly  overstepping  the  bounds  of  physiological  irritation,  is 
increased  by  all  sorts  of  minor  irritants,  such  as  inherited 
weakness,  impoverished  nutrition,  blood  poisoning  etc.,  and 
we  are  surprised  to  find  that  the  stored-up  tension  is  suddenly 
released  and  an  outbreak  of  the  most  violent  emotion  occurs. 
Let  us  now  enter  upon  the  subject  proper. 

GENERAL    IRRITATION. 

Delirium.     Coma. 

Aside  from  the  peculiar  affections  of  the  brain  and  spine,  the 
general  irritation  of  the  nervous  system  results  oftenest  from 
the  presence  of  injurious  matter  in  the  blood  and  juices  of  the 
body.  Fermentative  and  pyrogenous  substances,  which  have 
been  absorbed  from  inflammatory  centres,  have  the  same  or  a 
similar  effect  as  any  poison  which  enters  the  circulation  directly 
from  without.  But  since  many  of  these  harmful  substances 
are  of  themselves  fever-producing,  it  is  not  always  possible  to 
distinguish  their  effect  upon  the  central  nervous  system  from 
that  of  the  increased  blood  temperature,  and  vice  versa,  to 
determine  to  what  degree  the  constantly  irritated  nervous 
system  is  responsible  for  the  febrile  increase  of  temperature. 

In  what  are  called  general  symptoms,  the  periods  of  exci- 
tation and  exhaustion  are  not  sharply  defined.  A  sensation, 
sometimes  painful,  and  again  almost  agreeable,  passes  through 
the  body  and  forces  us  to  stretch  and  yawn.  It  is  associated 
with  lassitude  and  a  sense  of  heaviness  and  depression,  as  well 


86  GENERAL    PATHOLOGY. 

as  sleeplessness  and  headache.  The  latter  appears  to  signify 
a  more  severe  implication  of  the  central  nervous  system,  par- 
ticularly of  the  brain.  The  pain,  which  is  at  times  dull  and 
throbbing,  at  times  violent  and  lancinating,  results  partly 
from  the  cause  of  disease  and  partly  from  the  local  seat. 
There  follow  now  very  pronounced  indications  of  mental 
disorder,  in  all  degrees  of  intensity.  This  is  displayed  in 
general  restlessness,  uneasy  tossing,  and  hallucinations. 
Sounds  and  words  are  heard  and  imaginary  substances  are 
seen,  tasted,  and  smelled.  The  patient  endeavors  to  express 
these  rapid  impressions  in  incoherent  words,  and  we  then  say 
he  raves  or  is  delirious. 

This  overwrought  condition  is  followed  by  one  of  nervous 
depression,  the  degree  of  which  appears  to  be  determined  by 
the  preceding  exaltation.  The  patient  falls  into  a  state  of 
heavy  insensibility  (coma),  from  which  it  is  difficult  to  rouse 
him.  When  awakened,  he  is  in  a  drowsy,  semi-conscious 
state  (stupor).  In  extreme  depression,  the  sleep-like  insensi- 
bility is  accompanied  by  heavy,  stertorous  respiration  (sopor). 

Eclampsia. 

It  has  at  all  times  appeared  important  and  worthy  of  note 
to  physicians,  when  the  general  irritability  of  the  nervous 
system  produces  symptoms  which  denote  an  imperfect  control 
of  the  will  over  the  movements  of  the  body.  Nothing,  how- 
ever, conveys  so  absolute  an  impression  of  disease  or  abnor- 
mality as  the  abnormal  contraction  of  individual  muscles,  or 
groups  of  them,  which  reveals  to  us  the  whole  weakness  of  the 
human  spirit  as  contrasted  with  the  elementary  forces  of  nature. 
The  very  first  signs  in  this  direction,  like  the  familiar  "  gnash- 
ing of  teeth  "  and  "  rolling  of  the  eyes,"  have  something  ter- 
rible about  them.  Still  more,  that  peculiar  twitching  of  the 
fingers,  known  as  "  carphologia."  The  gravest  of  all 
symptoms  is  the  onset  of  general  convulsions — so-called 
Eclampsia. 

A  complete  eclamptic  attack  begins  with  a  very  powerful 
and  decided  contraction  of  the  flexor  muscles  of  the  back  and 
the  muscles  of  expiration.  A  piercing  cry  is  uttered,  the 
head  is  thrown  backwards,  the  face  upturned  and  a  little  to 
one  side,  the  arms  and  legs  become  stiff,  the  thumbs  turn  in, 
the  toes  are  turned  out,  and  the  soles  of  the  feet  are  bent 
together.  Then  follow  twitchings,  which,  beginning  in  the 


IRRITATION    OF   THE    NERVOUS   SYSTEM.  87 

terribly  distorted  countenance,  spread  first  to  the  arms  and 
thighs,  then  to  the  forearms  and  legs,  degenerating  finally 
into  a  general  convulsive  struggle.  A  moment  later,  the 
movements  become  less  violent,  and  at  last  cease  altogether. 

If  the  patient  has  not  been  previously  unconscious,  he 
becomes  so  at  the  beginning  of  the  attack,  and  continues  so 
for  ten  or  fifteen  minutes  after  it  has  subsided.  The  color  of 
the  face,  which  during  the  forced  expiration  was  livid,  grad- 
ually returns  to  normal,  and  only  a  few  ecchymoses,  the  size 
of  a  pin's  head,  remain  in  the  tender  skin  of  the  eyelids,  to 
remind  us  of  the  disturbances  which  have  occurred  in  the 
venous  blood. 

The  great  uniformity  of  these  groups  of  symptoms,  which 
reappear  in  identically  the  same  shape  in  epilepsy,  denotes 
that  we  have  to  consider  here  an  abnormal  excitement  or 
rather  lack  of  restraint  in  a  certain  circumscribed  region  of 
the  brain.  Nothnagel  has  fixed  this  region,  which  he  calls 
the  "  centre  of  convulsion,"  in  the  floor  of  the  fourth  ventricle, 
in  the  neighborhood  of  the  pons.  We  know,  beside,  from  the 
beautiful  experiments  of  Kussmaul  and  Tenner,  that  a  sudden 
anaemia  of  the  brain  produces  this  "  lack  of  restraint  "  in  the 
centre  of  convulsion  most  infallibly.  The  same  effect  is  also 
produced  by  the  ligature  of  a  vein  and  the  consequent  over- 
loading of  the  brain  with  venous  blood.  In  both  of  the  above 
instances  oxygen  is  lacking,  for  it  is  well  known  that  no  brain 
activity  can  exist  without  a  bountiful  supply  of  oxygen 

We  must  also  admit  the  possibility  of  a  partial  irritation 
or  lack  of  restraint  of  the  centre  of  convulsion,  because 
it  has  often  been  observed  that  the  eclamptic  attacks  appear 
incomplete  and  to  a  certain  degree  disconnected,  so  that  the 
"  hydrocephalic  cry  "  or  "  convulsions  "  are  the  only  visible 
symptoms. 

LOCAL  IRRITATION. 

Pain. 

A  local  irritation  of  the  nervous  system,  produced  by  the 
continuance  of  a  local  inflammatory  or  new-formation  process, 
appears  in  its  slight  degrees  as  a  vague  local  impression,  as  of 
weight,  pressure,  fullness,  etc.  Then  the  sensation  of  pain 
begins.  The  whole  may  be  likened  in  character  to  the  sound 
produced  by  gently  running  the  moistened  finger  around  the 
edge  of  a  fine  glass,  half  filled  with  water,  the  tone  being  first 


88  GENERAL   PATHOLOGY. 

low  and  intermittent,  then  continuous  and  increasing  in  vol- 
ume until  it  finally  rings  out  with  a  shrill  and  piercing  noise. 
The  intensity  of  pain  depends,  on  one  hand,  upon  the  severity 
of  the  irritation,  on  the  other,  upon  the  sensitiveness  of  the 
sufferer.  The  manifold  qualities  ascribed  to  pain,  such  as 
lancinating,  boring,  burning,  cutting,  darting,  depend  upon 
factors  as  yet  unknown.  The  same  applies  to  the  different 
parsesthesias  of  the  skin,  such  as  formication,  itching,  etc. 
The  centre  of  pain,  i.  e.,  -which  portion  of  the  central  nervous 
system  must  be  most  powerfully  irritated  in  order  to  allow 
the  sensation  of  pain  to  arise,  is  as  yet  a  disputed  point. 
Schiff  locates  it  in  the  gray  matter  of  the  spinal  cord,  and  to- 
day the  majority  of  observers  agree  with  him.  The  nerves 
of  special  sense  of  the  brain  might,  however,  be  cited  as  an 
exception. 

A  distinct  periodicity  is  observed  in  the  course  of  a  painful 
disease.  Moderate  pain  is  often  followed  by  only  a  short 
remission,  but  as  the  pain  becomes  more  intense,  the  remis- 
sion is  also  more  marked,  until  that  alternation  of  strong 
exacerbation  and  complete  remission  is  reached  which  we 
find  in  the  neuralgias. 

Pain  is  a  prominent  symptom  of  a  local  irritation  of  the 
nervous  system,  but  is  by  no  means  the  only  one,  because  it 
is  not  the  pain  which  is  essential,  but  the  centripetal  excite- 
ment, which  explains  many  other  reflexes,  which  are  partly 
of  a  vasomotor,  partly  of  a  sensitive  and  musculo-motor 
nature.  One  of  the  commonest  reflexes  is  an  active 
hypersemia  of  the  painful  part,  after  which  the  same  con- 
dition occurs  in  the  rest  of  the  organs.  More  rarely  there 
is  a  convulsive  contraction  of  single  arterial  twigs,  followed 
by  anaemia.  Prominent  among  the  sensitive  appearances  are 
"  sympathetic  affections,"  which  first  affect  symmetrical,  later 
totally  distant  parts.  Among  the  musculo-motor  reflexes 
may  be  enumerated  conscious  and  voluntary  movements, 
which  serve  the  purpose  of  modifying  and  diverting  pain, 
from  which  are  to  be  distinguished  involuntary  reflexes,  which 
consist  in  spasmodic  contractions  of  the  muscles.  Among 
the  latter  a  peculiarly  typical  group  of  symptoms  deserves 
special  mention. 


IRRITATION    OF   THE    NERVOUS   SYSTEM.  89 

Trismus  and  Tetanus. 

The  chief  symptom  of  "  lockjaw  "  is  a  continued  tonic  con- 
traction of  the  muscles,  which  begins  with  a  stiffness  in  the 
neck,  passes  thence  to  the  muscles  of  the  lower  jaw  and  face, 
and  finally  affects  the  whole  spinal  column.  When  fully  de- 
veloped, the  spinal  column  is  bent  backwards,  the  breast 
arched  forwards,  and  the  epigastrium  drawn  in.  Everything 
is  rigid.  The  jaws  are  closed,  the  teeth  firmly  shut,  and  the 
features  distorted  (risus  sardonicus}.  In  many  instances,  the 
tension  of  the  muscles  is  increased  spasmodically,  whereby 
the  body  is  hurled  violently  forward,  the  head  buried  in  the 
pillows,  and  the  tongue  bitten.  After  a  short  duration  of  the 
lockjaw,  death  generally  occurs,  from  paralysis  of  the  lungs 
and  heart. 

A  local  irritation  of  the  nervous  system  plays  the  chief  part 
in  producing  these  greatly  dreaded  symptoms.  Wounds  are 
the  chief  cause  of  tetanus,  especially  gunshot  wounds,  but  all 
lacerated  and  punctured  wounds  may  produce  it.  Tetanus  may 
set  in  immediately  after  the  wound  has  been  received,  during  its 
cleansing,  during  suppuration,  and  preferably  even  during  and 
after  cicatrization.  Improper  treatment,  the  presence  of  foreign 
substances  in  the  scar,  and  tension  exerted  on  the  nerves  by 
cicatricial  tissue,  are  influential.  In  any  case  a  permanent  dis- 
turbance of  the  central  nervous  system  proceeds  from  the 
wound.  This  is  not  particularly  painful,  but  is  so  peculiar,  that 
in  consequence  of  the  cumulative  irritation,  increased  reflex 
activity  is  permanently  established.  Once  established,  even 
a  slight  touch  or  a  sudden  draft  will  occasion  a  renewed  out- 
break of  the  above-described,  powerful  reflex  spasms.  For 
this  reason  cold  has  been  advanced  as  an  immediate  cause  of 
the  tetanic  spasm,  and  every  one  who  has  witnessed  the  out- 
break of  tetanus  on  the  battle-field  will  admit  that  there  is 
some  truth  in  the  matter. 

Shock. 

If  a  large  number  of  sensitive  nerve  fibres  be  irritated  at 
one  time,  as  occurs  occasionally  in  great  surgical  operations 
and  other  severe  lesions,  the  subsequent  irritation  of  the 
central  nervous  system  resembles  the  effect  produced  by  a 
stroke  of  lightning.  In  death  by  lightning,  we  assume  an 
excessive  and  irreparable  alteration  in  the  molecular  structure 
of  the  nervous  system.  The  lesions  in  shock  are  probably  of 
7 


90  GENERAL   PATHOLOGY. 

the  same  nature.  Its  symptoms  are :  deathly  faintness,  pallor 
of  the  face,  weak  heart  and  slowed  respiration,  resulting  in 
immediate  or  gradual  death.  Apart  from  this  fatal  form  of 
shock,  there  are  a  number  of  milder  varieties ;  among  them, 
the  transient  feeling  of  faintness  which  is  produced  by  a 
slight  blow  on  the  stomach.  Everywhere  the  process  results 
from  a  concussion  of  the  molecular  structure  of  the  central 
nervous  system,  which  possesses  the  physiological  value  of  an 
irritation  affecting  chiefly  the  centres  of  respiration  and  those 
which  preside  over  the  heart. 


III.  PHYSIOLOGICAL  EXTENSION  OF 
DISEASE. 

SYMPATHETIC  GROUPS  OF  SYMPTOMS. 


INTRODUCTION. 

A  new  series  of  typical  groups  of  symptoms  arises  from  the 
fact  that  each  organ  of  the  body  plays  a  certain  part,  or  does 
not  play  it,  not  only  for  itself,  but  also  for  the  entire  organism, 
whether  normal  or  deranged. 

The  work  contributed  by  the  various  organs  differs  widely 
in  relative  value,  and  the  diseased  conditions  to  be  described 
in  this  section  are,  in  consequence,  very  varied,  as  regards 
"  danger  to  life."  There  is,  however,  no  part  without  its 
function,  and  in  every  local  disorder  a  consideration  of  this 
fact  may  aid  us  to  foretell  what  symptoms  will  follow  a  cessa- 
tion or  an  impairment  of  the  function  of  an  organ.  In  many 
instances,  such  consideration  leads  us  to  a  well-marked  typical 
group  of  symptoms ;  in  others,  again,  it  fails  us.  To  the 
symptoms  of  the  functio  Icesa  are  added  additional  symptoms, 
which  arise  from  the  desire  of  the  organism  to  substitute  the 
disturbed  function  by  the  work  of  the  healthy  parts.  We  must 
consider  whether  and  how  far  these  so-called  vicarious  functions 
accomplish  their  object,  and  whether  the  organs  implicated  in 
this  unusual  work  do  or  do  not  suffer  in  consequence.  We  only 
assert  that  the  mingling  of  the  symptoms  of  the  functio  vicaria 
with  those  of  the  functio  Icesa  produces  in  many  cases  the  "  typi- 
cal symptoms  "  which  are  pathognomonic  of  disease  in  a  cir- 
cumscribed portion  of  the  body. 

A.  VEGETATIVE  DISTURBANCES. 
Man's  vegetative  organs  are  divided  into  three  classes  :  those 
presiding  over  hsematosis ;  those  presiding  over  the  circulation 
of  the  blood  ;  those  which  purify  the  blood.    The  effects  of  their 
operation  must  be  considered  conjointly.     The  organism  must 
be  richly  provided  with  good  and  pure  nutritive  material,  of 
a  constant  composition  and  temperature,  as  a  necessary  pre- 
91 


92  GENERAL  PATHOLOGY. 

liminary  to  a  thriving  nutrition.  Where,  however,  one  of 
the  organs  fails  to  do  its  work,  the  failure  is  apparent,  first,  in 
a  quantitative  or  qualitative  deterioration  of  the  blood,  or  in 
a  sluggish  circulation,  according  as  the  digestive  tract  and 
the  spleen,  the  heart  and  the  blood  vessels,  or  the  lungs,  kid- 
neys, and  liver  are  respectively  the  seat  of  the  local  trouble. 
The  second  result  of  the  failure  is  a  disturbance  of  the  gen- 
eral function  of  the  vegetative  system,  i.  e.,  the  nutritive  blood 
supply  of  the  body  and  its  parts.  Thus  we  separate  from  the 
special  group  of  symptoms  a  general  one,  which  may  be 
designated  as  Disturbances  of  Nutrition,  resulting  from  in- 
sufficient blood  supply. 

I.    DISTURBANCES  OF  NUTRITION. 

This  general  range  of  symptoms  takes  the  precedence  of 
all  others.  As  I  write  the  heading,  however,  I  feel  inclined 
to  question  the  manner  in  which  it  is  usually  employed.  Are 
not,  in  point  of  fact,  all  the  changes  which  we  have  considered, 
— inflammation  and  the  formation  of  tumors,  metastases  and 
fever,  indeed  almost  every  disease, — disturbances  of  nutrition 
as  well  ?  We  must,  therefore,  limit  ourselves  to  those  dis- 
turbances of  nutrition  which  are  such  in  the  strict  sense  of 
the  word,  i.  e.,  the  arrest  or  abolition  of  normal  assimilation, 
which  is  the  general  result  of  poor  and  insufficient  blood. 
But  might  they  not  also  be  the  product  of  totally  different 
factors,  such  as  direct  injury  to  the  cells  and  tissues  by  chem- 
ical, physical,  or  other  agents,  or  perhaps  from  disturbances  of 
normal  innervation  ?  Without  doubt.  But  we  need  not  regard 
these  minor  considerations.  On  the  other  hand  the  "  typical, 
universally  accepted"  character  of  these  changes  is  the  more 
distinctly  illustrated,  when  we  perceive  that  they  re-appear 
in  a  similar  manner  as  a  result  of  the  most  varied  causes. 

When  the  skin  and  the  visible  mucous  membranes  are 
bloodless,  the  eyes  sunken,  the  lips  dry,  the  energy  gone,  and 
the  weight  diminished,  we  say  a  person  is  badly  nourished, 
debilitated  and  decrepid.  A  portion  of  these  symptoms  may 
be  referred  directly  to  a  decrease  and  deterioration  of  the 
blood,  such  as  paleness  and  absence  of  color  in  the  skin ;  others 
are  indirectly  traceable  to  a  change  in  the  excitability  of  the 
nervous  system,  and  to  consumption  of  the  tissues  of  the  body. 
We  also  foresee  that  a  continued  operation  of  cause  and  effect 
will,  ultimately,  prove  fatal  to  the  diseased  body. 


DISTURBANCES    OF   NUTRITION.  93 

If  we  investigate  the  matter  more  closely,  and  examine 
such  a  body  microscopically,  we  are  soon  convinced  that  decay 
is  imprinted,  not  alone  upon  the  prominent  features  of  an 
individual,  but  can  also  be  demonstrated  in  the  individual 
parts.  We  find  certain  typical  changes  occurring  in  cells 
and  tissues,  which  characterize  the  retrogression  of  nutrition, 
and  perceive  that  these  changes,  appearing  in  certain  places 
in  the  otherwise  healthy  body,  disturb  the  regular  process  of 
assimilation. 

The  death  of  cells  and  tissues  stands  at  the  head  of  the 
cellular  pathological  conditions.  Death  is  the  suspension  of 
activity  in  living  matter,  produced  by  an  excessive  alteration 
in  the  chemico-physical  constituents  of  a  part.  In  the 
abstract,  death  is  always  a  sudden  event,  but  it  is  possible  that 
it  may  be  preceded  by  an  alteration  of  the  living  tissue, 
shorter  or  longer  in  duration,  so  that  a  sudden  or  gradual 
loss  of  function  may  represent  a  stage  between  life  and  death. 
Gradual  decay  is  called  "  Necrobiosis,"  sudden  death, 
"  Necrosis."  It  is  not,  however,  possible  to  lay  down  a  strict 
line  of  division,  because  it  is  rarely  possible  to  fix  the  exact 
moment  at  which  death  becomes  inevitable. 

(a)  NECROSIS. 

If  a  living  cell  be  treated  with  various  chemical  or  physical 
agents,  due  care  being  taken  not  to  overstep  a  certain  mod- 
erate degree  of  intensity,  we  notice  that  the  vital  mobility  of 
the  part,  so  far  as  this  is  visible,  is  excited  or  increased.  The 
colorless  blood  corpuscles  become  more  active,  the  cilia  of  the 
cylindrical  epithelium  lash  themselves  to  and  fro.  But,  on 
the  other  hand,  if  the  cells  be  treated  with  the  same  agents 
increased  in  strength,  if,  for  example,  a  colorless  blood  cor- 
puscle be  heated  a  few  degrees  higher  than  its  normal  tem- 
perature, or  be  placed  in  distilled  water,  dilute  acids  or  alka- 
lies, or  subjected  to  a  strong  electrical  current,  we  notice  that 
it  contracts  into  the  smallest  possible  compass,  becomes  gran- 
ular, cloudy  and  globular,  then  breaks  down  and  dissolves. 

In  the  above  succession  of  phenomena  we  have  the  general 
anatomical  picture  of  the  simple  death  of  a  cell,  viz.,  a 
rigidity  or  "rigor"  (Erstarrung),  followed  by  a  breaking  down 
of  the  protoplasm. 

This  rigidity  is  due  to  the  coagulation  of  an  albuminous 
substance  dissolved  in  the  living  protoplasm.  By  inter- 
preting it  as  a  last  tonic  contraction,  we  accept,  to  a 


94  GENERAL   PATHOLOGY. 

certain  degree,  the  supposition  that  vital  contractility  de- 
pends upon  a  transitory  consolidation  of  a  liquid  substance. 
This  view  is  borne  out  by  the  fact  that,  under  favorable  circum- 
stances, this  "  rigor  "  of  death  passes  over,  and  cells  which  are 
completely  motionless  again  resume  their  full  activity. 
Motionless  colorless  blood  corpuscles  become  active  upon  the 
addition  of  a  weak  salt  solution,  those  which  are  inactive 
through  excessive  heat,  by  lowering  the  temperature.  We  can 
produce  in  the  colorless  blood  corpuscle  of  a  frog,  by  means 
of  a  solution  of  quinine  or  carbolic  acid,  a  rigidity  which  may 
last  for  hours  before  the  corpuscles  again  resume  their  activity. 
But  if  this  rigidity  has  become  irrevocable,  the  subsequent 
dissolution  of  the  cells  is  only  a  matter  of  time.  ^See  Cloudy 
Swelling,  p.  31). 

Simple  necrosis  acts  upon  all  protoplasmic  constituents  of  the 
animal  body,  as  upon  the  colorless  blood  corpuscles.  Modifi- 
cations are  produced,  on  one  hand,  by  a  change  of  external 
conditions,  on  the  other,  by  the  transformation  of  protoplasm 
into  another  tissue. 

Ked  blood  corpuscles  appear  to  dissolve  without  previous 
contraction.  But  might  not  the  coagulation  of  the  blood  be 
regarded  as  their  death  ?  It  has  never  been  asserted  that  the 
liquor  sanguinis  lives,  but  if  we  accept  the  fact  that  coagula- 
tion of  the  blood  is  prevented  entirely  through  the  influence 
of  the  living  blood  vessel  wall,  is  it  possible  to  regard  this 
influence  otherwise  than  as  a  species  of  vivification  of  those 
albuminous  elements  which,  in  the  coagulated  state,  are  fibrin  ? 
We  shall  revert  to  the  subject. 

We  must  admit  that  the  hardening  and  contraction  of  the 
muscles  of  the  body,  which  generally  sets  in  rapidly  after 
death,  is  rightly  named  "  rigor  mortis."  Rigor  mortis  is  also 
observed  in  single  muscular  fibres.  It  is  accompanied  by  a 
granular  cloudiness  of  the  contractile  substance.  This  cloudi- 
ness is  somewhat  increased  before  dissolution.  A  species  of 
rigor  is  also  observable  in  nerves.  Probably  the  so-called 
coagulation  of  the  nerve  medulla  may  be  regarded  as  such. 

The  intercellular  substances  suffer  the  least  change  before 
liquefaction.  We  can  scarcely  perceive  a  cloudiness,  to  say 
nothing  of  a  coagulation.  The  calcareous  osseous  tissue  obsti- 
nately resists  liquefaction,  and  lasts  for  centuries. 

Of  course,  the  above  described  changes  take  place  only 
when  sufficient  moisture  is  present  to  liquefy  the  dead  parts, 


DISTURBANCES   OF   NUTRITION.  95 

and   wheii    there   is   no   obstacle  to   the   chemical   changes 
associated  with  the  liquefaction. 

Moist  gangrene  becomes  dry  gangrene  by  evaporation. 
When  a  dead  part  is  completely  dessicated,  it  lasts  for  thou- 
sands of  years,  as  in  the  case  of  Egyptian  mummies.  Again, 
corpses  lying  on  moist  clay,  and  continually  bathed  with  mois- 
ture, are  transformed  into  a  soap-like  substance,  called  adi- 
pocere.  This  substance  is  also  very  durable,  and  resists 
decomposition. 

(6)    SIMPLE  ATROPHY. 

Simple  Atrophy  is  that  diminution  in  the  volume  of  a  part, 
which,  as  revealed  by  the  microscope,  is  due  to  a  corresponding 
wasting  of  the  elements  of  the  parenchyma.  An  atrophied 
muscular  fibre  is  narrower  than  the  normal,  an  atrophied 
fat  cell  contains  less  fat  than  normal ;  in  other  respects,  its 
appearance  is  natural,  or  nearly  so.  We  frequently  observe 
a  brown  pigmentation  of  the  atrophied  cells,  without  being 
able  to  state  in  a  single  case  where  or  how  it  was  formed. 
The  cells  of  the  heart  muscle  produce  a  brownish-yellow  pig- 
ment, which  is  situated  in  the  small  masses  of  protoplasm 
above  and  below  the  nucleus,  the  striae  being  distinct  as  usual. 
In  the  atrophied  liver-cell  there  appears  regularly  a  granular, 
yellowish-brown  pigment,  shading  into  black.  One  would  be 
tempted  to  attribute  this  to  the  coloring  matter  of  the  bile,  if 
we  could  prove  it  by  micro-chemical  reactions.  The  fat  in 
atrophied  fat  cells  is  colored  brown ;  this  can  be  readily  per- 
ceived with  the  naked  eye,  although  the  origin  of  the  color  is 
extremely  uncertain. 

Simple  atrophy  is  primarily  the  outward  expression  of  a 
general  lowering  of  the  processes  of  nutrition.  The  immedi- 
ate cause  of  this  might  well  be  diminution  in  the  quantity 
and  in  the  arterial  pressure  of  the  blood.  Again,  simple 
atrophy  occurs  in  local  diseases  of  organs,  especially  when 
these  are  associated  with  a  gradual  retardation  of  the  inter- 
mediary nutritive  changes,  occurring  in  single  large  or  small 
portions  of  the  parenchyma  (closure,  compression  of  blood 
vessels,  etc.) 

(c)    FATTY,  MUCOUS,  COLLOID   DEGENERATION. 

There  exists,  besides  simple  or  quantitative  atrophy,  another 
series  of  disturbances  of  nutrition  in  the  tissues,  which  are 


GENERAL   PATHOLOGY. 


typified  in  the  physiological  development  of  the  epithelial 
cells.  As  the  epithelial  cells  continue  to  grow  they  remove 
farther  and  farther  from  their  original  place,  which  is  usurped 
by  their  progeny,  and  the  nutritive  fluid  must,  in  conse- 
quence, travel  farther  to  reach  them.  This  circumstance, 
combined  with  the  pre-established  law  of  epithelial  growth, 
causes  the  structure  of  the  older  cells  to  undergo  changes, 
which,  being  in  the  nature  of  a  gradual  dying  out,  are 
entitled  to  be  styled  necrobiotic.  In  the  careful  economy  of 
the  human  system  nothing  goes  to  waste,  and  so  this  death 
and  separation  of  the  epithelial  cells  is  put  to  a  practical  use, 
viz.,  the  dessicated  epidermal  cells  are  converted  into  a  thick 
and  impervious  crust,  the  horny  layer  of  the  epidermis 
(keratin}.  The  mucus  which  overspreads  the  surface  of  the 
mucous  membranes  owes  its  origin  to  a  mucous  exudation  of 
the  epithelia  of  the  mucous  membranes  and  glands  (mucin). 
The  epithelia  which  cover  the  closed  follicles  of  the  thyroid 
gland  furnish  the  colloid  substance,  which  flows  in  and  fills 
to  expansion  the  lumen  of  the  vesicles,  a  process  which  would 
very  well  harmonize  with  the  suspected  function  of  the  gland. 
The  ovary  is  ruptured  by  the  discharge  of  a  similar  substance 
in  menstruation.  The  fatty  metamorphosis  of  the  epithelia 
of  the  mammary  glands  leads  to  lactation ;  that  of  the  seba- 
ceous glands  to  the  formation  of  sebaceous  matter.  Beside 
all  these  there  are  many  metamorphoses  of  glandular  epithelia 
which  lead  to  the  ferment- endowed  secretions  of  saliva,  gastric 
juice,  etc. 

Of  these  metamorphoses,  the  fatty,  mucous  and  colloid  are 
those  chiefly  met  with  among  pathological  necrobioses.  All 
three  lead  to  the  formation  of  such  chemical  products  as  are 
soluble  in  water,  or,  at  least,  absorb  it  readily,  on  which 
account  they  are  apt  to  appear  to  the  naked  eye  as  softenings 
or  liquefactions.  The  loss  of  consistency  proceeds  by  an 
almost  imperceptible  process,  in  which  the  normally  tough 
and  elastic  tissue  passes  through  various  stages  of  pulpy 
maceration  till  it  finally  resolves  itself  into  fluctuating  centres 
of  liquefaction.  If  this  stage  continue,  and  the  softened 
matter  is  not  liberated,  the  liquefying  centre  becomes  by  con- 
tinued breaking  down  more  and  more  distinct  from  the  sur- 
rounding parenchyma,  and  forms  a  cyst,  which  we  distinguish 
from  the  membranous  (retention)  cyst  by  calling  it  a  softening 
cyst. 


DISTURBANCES   OF   NUTRITION.  97 

Fatty  Degeneration. 

Fatty  degeneration  is  a  gradual  but  certain  liquefaction  of 
cell  protoplasm  and  other  albuminous  and  albuminoid  struc- 
tures, which  is  initiated  by  the  appearance  of  fat-drops  in  the 
centre  of  the  part.  Under  the  microscope,  these  drops  look 
like  small,  dark  points  and  granules.  They  increase  by 
degrees,  and  often  unite  into  medium-sized  drops,  though  never 
into  a  single  large  one.  The  substratum  becomes,  at  last,  so 
completely  permeated  that  it  resembles  a  mass  of  dark 
granules. 

In  the  degeneration  of  single  cells,  we  have,  at  this  stage  of 
the  metamorphosis,  the  "  compound  granule  cell."  The  old  cell 
outlines  are  no  longer  distinct,  because  the  fat-drops  penetrate 
to  and  project  beyond  the  outer  surface.  The  corners  and  edges 
of  the  normal  cell  have  vanished,  and  the  whole  is  converted 
into  a  spherical  ball.  The  nucleus  and  nucleolus  are  not 
perceptible,  but  can  be  made  so  by  treating  them  with  carmine. 

The  compound  granule  cell  is,  nevertheless,  not  the  invari- 
able product  of  the  fatty  degeneration  of  a  single  cell.  If  the 
fatty  degeneration  attack  a  connective  tissue  provided  with 
stellate  cells,  and  the  liquefaction  of  the  cell  is  preceded  by 
the  usual  dissolution  of  intercellular  substance,  the  aggregated 
fat-drops  are  stellate,  like  the  cells  which  they  replace. 

In  degeneration  of  the  striated  muscles,  the  fat-drops  form, 
at  first,  rows  of  pearly  beads  running  parallel  with  the  fibrils. 
As  they  multiply,  and  become  more  evenly  distributed  through- 
out the  muscular  fibres,  the  stronger  refractive  power  of  the 
fat-drops  overcomes  the  optical  effect  of  the  muscle,  and  the 
striation  disappears.  Tiny,  dust-like  fat-drops  form  upon  the 
muscular  cells  of  the  heart;  the  striation  disappears  here  also, 
and  is  replaced  by  an  even  and  finely  punctated  exterior. 

Moderate  degrees  of  fatty  degeneration  are  compatible  with 
a  continuance  of  life,  and  the  re-establishment  of  normal  con- 
ditions. When,  however,  the  degenerated  tissue  has  become 
thoroughly  impregnated  with  fat-drops,  we  may  assume  that 
the  vital  functions  have  ceased  to  act,  and  that  the  further 
adhesion  of  the  fat-globules  is  purely  mechanical. 

With  a  sufficient  amount  of  moisture,  we  may  expect  to 
see  the  fat-drops  disorganize  and  emulsify  into  a  milky  fluid, 
called  "  fatty  detritus."  This  is  absorbed  as  readily  as  milk 
would  be  into  the  lymphatics  and  carried  away.  The  condition 
of  re-absorption  must  be  unusually  unfavorable  if  this  fatty 


98  GENERAL   PATHOLOGY. 

detritus  is  permitted  to  remain  and  undergo  further  change. 
The  same  process  occurs  in  yellow  softening  of  centrally-situ- 
ated parts  of  the  brain ;  the  thick  layer  of  brain  substance 
surrounding  the  centre  of  softening  cannot  sink  in,  in  case 
the  fatty  detritus  be  absorbed,  neither  can  the  skull.-  Con- 
sequently, the  fatty  detritus  must  remain,  as  if  to  fill  in  the 
breach.  Also  when  fatty  detritus  has  accumulated  in  the 
tough  intima  of  arteries,  there  is  no  possibility  of  absorption. 
The  mass,  which  becomes  thick  and  doughy,  and  contains 
quantities  of  glistening  cholesterin  crystals,  is  called,  from  a 
fancied  resemblance  to  gruel,  "  atheromatous  pulp." 

So  much  for  the  morphology  of  fatty  degeneration.  The 
most  important  of  all  its  phenomena  is  the  formation  of  fat 
by  the  splitting  up  of  albuminous  substance,  a  fact  indubitably 
proved  by  physiological  chemistry.  We  assume  that  in  true 
fatty  degeneration  the  albumen,  which  constitutes  a  part  of  the 
cell  protoplasm  and  its  derivatives,  is  disorganized  into  fatty 
and  other  products,  and  that  the  well-known  insolubility  of 
fat  in  a  watery  medium  makes  it  visible  in  the  interior  of  the 
degenerated  part.  The  organized  remainder  acts  for  a  time 
as  a  cement  upon  the  whole,  but  yielding  gradually,  it  be- 
comes soluble  (casein,  sodic  albuminate),  after  which  its 
complete  disintegration  and  conversion  into  a  pathological 
milk  is  merely  a  question  of  time  and  opportunity. 

Mucous  Metamorphosis. 

Mucin  is  a  product  of  cell  albumen,  without  sulphur, 
and  noted  for  its  tendency  to  swell  up.  Mucus  is  furnished 
not  only  by  cells,  but  also  by  the  matrix  of  the  various  con- 
nective tissue  substances,  viz.,  the  connective  tissue  fibres  and 
the  matrix  of  cartilage  and  of  bones.  Whenever,  therefore, 
we  meet  with  mucin,  we  may  be  sure  that  it  comes  directly 
from  cells  or  their  derivates.  Its  manner  of  origin  is  compara- 
tively simple.  The  cell  protoplasm  becomes  homogeneous,  and 
concentrates  in  constantly  increasing  bulk  around  the  nucleus, 
where  there  is  gradually  formed  a  spherical  drop,  which  in- 
creases in  transparency,  and  upon  the  addition  of  acetic  acid, 
shows  a  stringy,  mucous  coagulum.  The  drop  in  growing  dis- 
places the  nucleus,  which,  after  the  complete  disintegration  of 
the  protoplasm,  breaks  down  into  a  heap  of  glistening  frag- 
ments, which  persist  for  some  time. 

The  matrix  of  the   connective   tissue   and   cartilage   be- 


DISTURBANCES  OF   NUTRITION.  99 

comes  soft,  transparent,  and  spongy.  The  addition  of  acetic 
acid  betrays  the  mucous  metamorphosis  by  a  distinct  cloudi- 
ness. Little  by  little  the  constituents  dissolve,  although  the 
original  shape  may  be  retained  for  a  considerable  time  by  the 
addition  of  acetic  acid,  which  produces  a  sort  of  coagulation. 
The  macroscopical  effect  of  mucous  degeneration  is  highly 
characteristic.  Since  the  mucus  is  not  soluble,  it  is  perceptible 
even  in  small  quantities.  It  imparts  to  fluids  a  "  stringiness ;" 
to  solids,  a  "  slippery  property."  When  a  tissue  has  undergone 
complete  mucous  degeneration,  it  assumes  a  "  gelatinous,  tremb- 
ling" consistence. 

Colloid  Metamorphosis. 

Colloid  metamorphosis,  called  by  Von  Recklinghausen 
"  hyaline,"  is  very  closely  allied  to  mucous  degeneration. 
The  colloid  substance  absorbs  water  with  equal  eagerness, 
and  yields  solutions,  which,  though  very  similar,  are  of  a 
more  synovial  character  than  those  of  mucin.  The  colloid 
substance  forms  with  water  a  large  number  of  combinations 
of  varying  consistency.  One,  in  particular,  greatly  resembles 
partially  dissolved  glue,  from  which  appearance  the  name 
"colloid"  was  derived.  The  colloid  matter  itself  contains 
sulphur,  and  is  fundamentally  an  albuminous  body,  but  differs 
from  albumen  and  all  other  protein-substances  by  the  absence 
of  characteristic  chemical  reactions.  It  does  not  coagulate 
when  subjected  to  heat,  and  may  be  kept  for  years  in  alcohol 
without  losing  its  translucency.  It  is  also  not  acted  upon  by 
the  chemical  juices  of  the  body,  as,  for  instance,  the  gastric 
juice.  Its  power  of  resistance  increases  with  age,  but  it  yields, 
finally,  though  slowly,  to  decomposition. 

Colloid  matter  is  formed,  partly  in  cells,  partly  from  albu- 
men which  has  been  deposited  in  the  neighborhood  of  such 
.cells  or  elsewhere  and  not  re-absorbed.  In  the  latter  case, 
there  is  a  gelatinous  formation,  such  as  may  be  produced  in  the 
serum  by  a  temperature  of  69°  C.  (156.2°  F.)  In  the  former, 
the  colloid  drop  appears  beside  the  nucleus  in  the  protoplasm, 
and,  as  in  mucous  metamorphosis,  the  nucleus  and  cell  con- 
tents about  it  are  first  compressed  and  finally  dissolved  and 
absorbed.  The  large  colloid  masses  which  then  arise  coalesce 
into  a  hyaline  contexture,  in  which,  later,  vacuoles  and  fissures 
are  often  perceptible. 

It  may  be  said  to  be  almost  a  matter  of  individual  taste, 


100  GENERAL   PATHOLOGY. 

whether  another  peculiar,  albuminous,  dropsical  softening  is 
to  be  reckoned  among  the  mucous  and  colloid  degenerations. 
An  abundant  permeation  with  stagnating  blood  serum  leads, 
naturally,  to  a  certain  swelling  and  liquefaction  of  the  cells 
and  tissues,  which  are,  however  devoid  of  characteristic  mor- 
phological characters. 

(d)    CALCIFICATION. 

Calcification  (petrifaction)  is  the  infiltration  of  cells  and 
tissues  with  the  carbonate  and  phosphate  of  lime,  together 
with  a  slight  amount  of  phosphate  of  magnesium.  The  deposit 
is  in  the  shape  of  the  smallest,  dust-like  molecules,  which, 
when  placed  under  the  microscope,  appear  white  and  glisten- 
ing by  reflected  light,  but  by  transmitted  light  are  of  a  dark 
color,  and  disappear  upon  the  addition  of  muriatic  acid.  As 
the  deposit  becomes  more  dense,  the  part,  even  to  the  naked 
eye,  presents  a  dull  white,  calcareous  color,  and  varies  to  the 
touch,  from  a  rough,  pumice-like  feeling  to  a  compact,  stony 
hardness.  With  all  this,  the  original  form  of  the  part  is  faith- 
fully maintained  in  the  calcification,  and  can  at  any  time,  by 
a  judicious  application  of  muriatic  acid,  be  restored. 

In  calcified  ganglion- cells  of  the  brain,  the  pointed  offshoots 
and  the  pyramidal  form  are  at  once  recognized ;  in  a  calcified 
tunica  media  arteriarwn,  we  see  the  transverse  bundles  of 
muscles;  and  in  a  calcified  cheesy  focus  of  the  lungs,  the 
conical  shape  of  the  phthisical  lobule. 

There  is  no  doubt  but  that  the  salts  of  lime,  which  are 
deposited  in  the  calcifying  parts,  are  derived  from  the  nutri- 
tive fluid.  Except  in  very  rare  instances  (as  in  calcareous 
metastases,  in  extensive  absorptions  of  the  osseous  system), 
this  is  not  the  result  of  an  unusual  accumulation  of  salts  of 
lime  in  the  blood.  The  chemical  reasons  for  calcification  are, 
consequently,  to  be  sought  in  the  special  peculiarities  of  the  dif- 
ferent parts.  The  first  and  foremost  agency  is  the  all  but  com- 
plete stoppage  in  the  flow  of  the  parenchymatous  juices.  It  is, 
therefore,  principally  dead  parts  which  become  superficially 
encrusted  with  calcareous  deposits.  In  this  manner,  the  small 
round  blood  coagula  of  the  vein  plexuses  are  converted  into 
vein-stones  (phlebolithes)  ;  the  cheesy  lobes  of  the  phthisical 
lung  become  lung-stones  (pneumoliths)  ;  and  even  entire  em- 
bryos, which  have  arrived  at  maturity  and  died  in  the  free 


DERANGEMENTS  OP  THE  CIRCULATION.  101 

abdominal  cavity,  become  petrified  to  a  depth  of  one-half  a 
centimetre  (lithopaedion). 

Second  in  importance  is  the  petrifaction  of  the  products  of 
pathological  overgrowth,  whose  demands  for  nutrition  can 
only  be  incompletely  satisfied  by  the  existing  nutritive  appa- 
ratus. The  most  simple  and  striking  example  of  this  is  found 
in  the  calcification  of  the  inflamed  and  thickened  intima  of 
the  heart  and  arteries.  The  intima  being,  even  in  its  inflamed 
condition,  devoid  of  blood  vessels,  suffers  from  an  impeded 
flow  of  nutritive  fluid,  and  the  thickest  spots  petrify.  The 
calcification  of  certain  tumors,  like  the  enchondromata  and 
fibromata,  comes  under  this  head. 

Then  follow  the  senile  calcifications,  which,  generally  stated, 
denote  a  deterioration  of  the  nutritive  juice  current,  and 
which  gradually  have  for  their  type  the  physiological  calcifica- 
tion of  cartilage  in  osteogenesis. 

II.  DERANGEMENTS  OF  THE  CIRCULATION. 

When  disturbances  of  circulation  arise  in  the  heart  or  large 
blood  vessels  we  call  them  general  or  central ;  when  they  arise 
in  small  branches  or  twigs  we  call  them  local.  In  the  neigh- 
borhood of  the  heart,  and  in  the  heart  itself,  the  circulatory 
apparatus  is  limited  to  a  single  path.  Here,  too,  the  chief 
mechanical  force  of  the  circulation  resides,  hence  anatomical 
changes  occurring  here  influence  the  whole  circulation,  while 
disturbances  of  the  circulation  occurring  in  the  capillaries  or 
small  arterial  or  venous  territory  rarely  have  much  effect 
upon  the  general  circulation. 

This  division  is  as  well  marked,  and  at  the  same  time  as 
illy  defined,  as  the  division  of  the  circulation  into  main 
trunk  and  branches.  If  all  the  branches  or  only  the  greater 
portion,  be  affected  by  an  anatomical  change,  the  disturbance 
will,  as  a  matter  of  course,  be  transmitted  to  the  general  cir- 
culation, precisely  as  if  the  main  trunk  were  affected.  In  this 
manner  lung  disease  and  affections  of  the  arteries  often 
produce  general  disturbances  of  the  circulation. 

The  local  disturbances  of  the  circulation  have  already 
been  dwelt  upon  to  a  certain  extent  in  connection  with  me- 
tastases  (Thrombosis  and  Embolism).  The  following  brief 
consideration  partakes,  consequently,  more  of  the  character 
of  a  scientific  summary.  Active  hypersemia  is  no  disturb- 
ance, but  rather  an  assistance,  to  the  circulation. 


102  GENERAL   PATHOLOGY. 

LOCAL  DERANGEMENTS. 

ARTERIAL. 

Ischoemia  and  Collateral  Circulation. 

The  moment  we  ligate  an  artery  leading  to  a  certain  part, 
the  blood  current  is,  of  course,  arrested,  and  the  muscular 
walls  of  the  artery,  thus  cut  off  from  the  general  circulation, 
contract  and  force  the  blood  for  the  last  time  through  the 
capillaries  into  the  veins.  The  part  is  now,  as  far  as  possible, 
in  a  bloodless  condition  (Ischsemia — local  arterial  ansemia. 
Virchow).  The  same  thing  happens  when  the  artery  is  com- 
pressed or  obstructed.  Whether  the  entire  region  supplied 
by  the  artery  is  to  remain  empty  depends  upon  circumstances. 
Most  of  the  arteries  of  our  body  have  collateral  branches. 
For  this  reason  the  bloodless  condition  of  a  part  only  lasts  for 
a  short  time,  and  by  the  so-called  development  of  collateral 
circulation  the  endangered  territory  is  soon  provided  with  a 
bountiful  supply  of  blood.  This  system  has,  however,  its 
defects.  It  is  plain  that  the  articular  branches  of  the  knee 
are  not  sufficient  to  carry  on  the  functions  of  the  obstructed 
popliteal.  Indeed,  there  are  vascular  areas  in  which  the  main 
trunk  and  its  branches  are  arteries  which  have  no  collateral 
circulation,  i.  e.,  end-arteries.  It  is  with  these  as  Avith  an 
actual  tree,  when  a  large  or  small  branch  is  broken  off  every 
thing  beyond  the  break  is  lost. 

The  vascular  territory  of  a  small  end-artery  can  be  filled, 
and  even  over-filled,  from  the  veins  afronte,  especially  if  there 
is  much  blood  pressure.  The  weak  and  distended  capillary 
walls  are  now  liable  to  burst  and  allow  the  blood  to  escape 
either  into  the  parenchyma  or  externally  ;  the  part  becomes 
excessively  distended  with  blood — infarcted — a  process  dwelt 
upon  at  length  on  page  71  in  connection  with  metastasis. 
This  blood  does  not  flow,  and  the  interchangement  of  the 
blood  particles  being  below  normal,  is  nearly  or  wholly 
arrested.  When  a  large  end-artery  is  occluded,  there  ensues 
a  permanent  absence  of  blood  in  the  organ,  Avhich  is  then 
followed  by  a  rapid  death. 

Every  disturbance  of  the  circulation  may,  in  reality,  be 
regarded  from  two  standpoints.  We  have  thus  far*  only  con- 
sidered the  condition  of  the  territory  from  which  the  blood 

*  I  again  call  attention  to  the  description  of  the  metastatic  pro- 
cesses, p.  58,  et  seq. 


LOCAL   DERANGEMENTS.  103 

has  been  cut  off.  We  must  now  speak  of  the  changes  occur- 
ring on  the  other  side  of  the  obstruction. 

First  in  importance  is  a  general  rise  of  arterial  pressure, 
proportional  to  the  size  of  the  obstacle,  and  extending  back- 
ward into  the  aorta,  causing  a  corresponding  increase  in  the 
work  of  the  left  ventricle  of  the  heart.  This  rise  in  pressure 
is,  however,  only  transient.  After  a  short  time,  one  or  more 
of  the  pervious  arteries  dilate  strongly,  and  while  the  general 
arterial  pressure  returns  to  normal,  there  arises  in  the  region 
supplied  by  the  above-mentioned  arteries  a  condition  called 
collateral  hypersemia.  Those  blood  vessels  situated  immedi- 
ately posterior  to  the  obstruction  are  by  no  means  those 
which  always  experience  this  collateral  dilatation.  This  only 
occurs  when  these  branches  are  able  to  carry,  in  the  most 
direct  manner,  the  necessary  blood  to  the  threatened  parts ; 
so,  for  instance,  the  numerous  anastomosing  muscular  and 
intestinal  blood  vessels.  But  if  the  internal  carotid  of  one 
side  be  obstructed,  it  is  not  the  external  carotid  of  the  same 
side  which  becomes  dilated,  but  instead  the  internal  carotid 
of  the  opposite  side.  The  collateral  dilatation  is  thus  deter- 
mined by  the  need  of  the  organism,  demanding,  primarily, 
blood  for  the  disabled  organ,  and,  secondarily,  for  that 
which  assumes  vicariously  the  function  of  that  organ. 
Thus  in  the  total  isolation  of  an  artery  of  the  kidney,  only 
one  of  the  numerous  arteries  of  the  lower  part  of  the  body 
dilates,  viz.,  the  artery  of  the  second  kidney,  and  the  collateral 
hypersemia  of  this  organ,  which  eventually  produces  a  col- 
lateral hypertrophy,  is  sufficient  to  cause  the  secretion  of  all 
urinary  products  from  the  blood. 

Here  again  we  encounter  that  mysterious  understanding 
between  the  organs  of  our  body,  i.  e.,  the  vascular  and  nervous 
systems,  which,  even  in  active  hypersemia,  awakens  our  well- 
deserved  astonishment,  and  reminds  one  of  the  original  con- 
secutive unity  of  all  processes,  where  a  demand  need  only  be 
expressed  to  be  at  once  supplied. 

VENOUS  DERANGEMENTS. 

Congestion  and  (Edema. 

In  order  to  understand  the  effects,  as  well  as  the  non-effects, 
of  a  local  interruption  of  the  venous  blood  current,  we  must 
call  to  mind  certain  features  of  normal  anatomy.  First  of 
all,  we  will  contrast  the  considerable  length  of  the  venous 


104  GENERAL  PATHOLOGY. 

channels  with  those  of  the  arterial.  Two  veins  of  nearly 
equal  size  return  the  blood  from  a  part  supplied  by  an  artery 
of  half  their  common  calibre.  These  veins,  together  with 
their  small  branches,  form  numerous  anastomoses  and  so-called 
plexuses.  In  addition  to  this,  there  is  almost  everywhere  a 
peripheral  network,  i.  e.,  an  arrangement  on  the  periphery 
of  a  part,  of  a  venous  network,  which  can  be  employed  in  case 
the  chief  channels  are  temporarily  blockaded  or  obstructed 
by  muscular  contraction.  As  such  substitutes  we  may  regard 
the  ramifications  of  the  saphenous,  basilic,  external  jugular, 
azygos,  and  hemiazygos  veins.  Also  in  some  glandular 
organs,  viz.,  in  the  lungs,  we  find  peripheral  plexuses  in  the 
interstitial  tissue  surrounding  the  lobules.  In  short,  nature 
seems  to  have  considered  the  possibility  that  a  venous  trunk 
might  sometimes  become  impervious  to  the  circulation,  and  to 
have  provided  for  the  emergency  by  establishing  numerous 
accessory  veins,  and  also  by  availing  herself  of  external  pres- 
sure to  contract  the  veins  and  strengthen  the  blood  current. 
From  what  has  already  been  said,  we  see  that  the  pathological 
compression  or  the  plugging  up  of  any  single  peripheral  vein 
is  followed  by  little  or  no  disturbance  in  the  integrity  of  the 
circulation. 

But  it  is  a  different  matter  when  the  majority,  and  some- 
times all,  the  veins  of  a  certain  territory  are  completely  oblit- 
erated, as  we  have  seen  in  thrombosis,  or  when  certain  tissues 
or  prominent  parts  are  strangulated  (strangulated  hernia). 
The  above  conditions  are  easily  produced  by  artificial  means  ; 
among  them  may  be  classed  acute  obstructive  or  static  con- 
gestion, or  venous  hypercemia.  The  most  prominent  symp- 
toms are  a  dark  bluish  (cyanotic)  discoloration,  a  swelling 
which  slowly  increases,  and  a  perceptible  diminution  in  the 
external  temperature  of  the  congested  part.  The  visible  veins 
are  over-distended,  markedly  convoluted,  or  spiral-shaped; 
the  valves  appear  as  nodules. 

The  microscopical  appearances  are  best  observed  in  the  leg 
of  a  frog,  after  the  femoral  vein  has  been  ligated.  The  veins, 
capillaries,  and  even  the  arteries,  distend  moderately,  the  blood 
moves  more  and  more  slowly,  until  the  motion  becomes  spas- 
modic and  synchronous  with  the  systole  of  the  heart.  The 
blood  corpuscles  adhere  so  closely  together  that  their  indi- 
vidual contours  are  finally  lost,  and  the  whole  appears  as  a 
continuous,  red  column.  After  the  lapse  of  forty-five  minutes, 


LOCAL   DERANGEMENTS.  105 

small,  roundish,  sacciform  elevations  are  seen  projecting  from 
the  walls  of  the  capillaries,  whereat  an  outwanderiug  of  the 
red  blood  corpuscles  begins.  They  escape  through  the  little 
crevices,  which  here  enlarge  to  form  real  stomata,  at  the 
junction  of  the  capillary  endothelial  cells.  The  blood 
emerges  in  small,  round  drops,  and  remains  temporarily  in 
the  connective  tissue.  In  the  course  of  three  or  four  days 
the  red  blood  corpuscles  lose  their  haemoglobin,  which,  being  set 
free,  causes  a  diffuse  and  granular  coloration  of  the  surrounding 
fluids  and  tissues.  This  coloration  will  be  considered  later, 
under  the  head  of  Hemorrhage  and  Pigmentation. 

We  must  at  this  point  consider  another  important  conse- 
quence of  acute  passive  congestion,  the  so-called  stagnation- 
oedema  (Stauungsodem),  i,  e.,  the  escape  of  a  certain  amount 
of  the  fluid  matter  of  the  blood  from  the  dilated  capillaries. 
This  is  the  direct  consequence  of  the  unusual  amount  of  lateral 
pressure  exerted  upon  the  weak  capillaries,  and  may  be 
regarded  simply  as  a  mechanical  filtration  of  liquor  san- 
guinis.  This  exuded  fluid  (the  transudate)  contains  the  usual 
definite  proportion  of  salts  and  water,  but  much  less  albumen 
than  blood  serum,  so  that  it  can  be  called  a  very  thin  serum. 
The  fluid  penetrates  the  connective  tissue  in  all  directions, 
fills  up  all  the  clefts,  and  collects  in  large  pools  in  the  pre- 
formed interstices  of  the  connective  tissue.  Finally,  it  oozes 
out  wherever  possible,  upon  the  surface,  and  the  part  in 
question  swells  up  and  becomes  doughy.  Its  further  fate 
depends  upon  the  removal  or  non-removal  of  the  obstruction 
to  the  circulation.  In  the  former  event,  everything  returns 
to  the  normal  state,  while  in  the  latter,  moist  gangrene  is  very 
apt  to  set  in. 

The  chronic  form  of  venous  congestion  arises  (1)  where  a 
permanent  compression  or  plugging  occurs  in  the  majority 
but  not  all  of  the  efferent  veins  of  a  certain  region,  so  that  the 
reflux  of  the  blood  is  hampered  but  not  completely  arrested  ; 
(2)  as  the  indirect  result  of  general  weakness  and  distensi- 
bility  of  the  venous  system.  We  know  how  weak  an  im- 
pulse venous  blood  receives.  That  imparted  by  the  heart  to 
the  circulation  is  perceptible,  although  greatly  weakened, 
beyond  the  capillaries,  and,  being  transmitted  thence  to  the 
veins  gives  an  additional  impulse  to  the  blood  contained  in 
them.  This  power  is,  however,  insufficient  to  propel  the 
blood  against  the  force  of  gravity  from  the  extremities  back 


106  GENERAL    PATHOLOGY. 

to  the  heart ;  and  were  it  not  that  valves  are  placed  at  in- 
tervals to  prevent  the  reflux  of  blood,  and  did  not  occasional 
contractions  of  the  muscles  force  the  blood  towards  the  heart, 
the  venous  circulation  of  the  extremities  would  be  badly  off. 
We  can,  therefore,  no  longer  wonder  that  abnormal  collections 
of  blood  occur  the  moment  even  an  auxiliary  factor  of  the 
circulation  fails  to  do  its  duty,  and  that  people  who  are  forced 
to  lead  sedentary  lives,  and  do  not  use  their  thigh  muscles,  are 
afflicted  with  varicose  veins  and  hemorrhoids.  The  yielding 
nature  of  the  venous  walls  aids  this  dilatation,  and  confirms 
the  diseased  condition  by  making  the  return  to  normal,  in  time, 
impossible. 

We  are  thus  brought  face  to  face  with  a  consequence  of 
special  moment  in  the  pathology  of  numerous  organs,  viz., 
we  may  expect  that  all  continued  or  repeatedly-recurring 
hypersemias,  be  they  inflammatory,  recurrent,  passive,  or  col- 
lateral, will  produce  in  the  venous  system  a  tendency  to  a 
permanent  dilatation.  This  dilatation  will  be  strong  in  pro- 
portion to  the  weakness  of  the  vein -wall  and  its  lack  of  power 
to  contract  to  its  normal  calibre  after  being  for  a  long  time 
excessively  distended.  This  is  especially  true  of  the  sinuses  of 
the  brain  ;  accordingly,  we  find  a  passive  hypersemia  of  the 
pia  mater  convexa,  accompanied  by  marked  dilatation  and 
sinuosity  of  the  veins,  and  by  a  watery  exudate  in  the  sub- 
arachnoid  space  (external  hydrocephalus),  the  inevitable 
result  of  the  most  varied  and  prolonged  hypersemias  of  the 
brain  (psychoses,  alcohol,  etc.)  In  the  latter  case,  particu- 
larly, one  phenomenon  is  observable  which  seems  to  charac- 
terize equally  all  chronic  congestive  hypersemias,  viz.,  a  hyper- 
plastic  condition  of  theperivascular  connective  tissue,  especially 
that  of  the  veins.  It  appears  here  as  a  milky  cloudiness  of 
the  pia  mater,  in  other  parts  as  an  induration  (kidney),  and 
more  rarely  as  a  partial  shrinking  (liver). 

HEMORRHAGE. 

In  view  of  the  rapid  advance  made  in  medical  science 
within  the  last  few  decades,  and  the  many  radical  changes 
of  opinion  attendant  upon  such  advance,  it  is  reassuring  to 
approach  one  subject,  the  views  with  regard  to  which  have 
for  years  undergone  no  substantial  modifications.  Such  is 
hemorrhage.  The  sudden  and  often  fatal  character  of  hemor- 
rhages has  always  caused  them  to  be  regarded  with  peculiar 


LOCAL    DERANGEMENTS.  107 

interest  both  by  physicians  and  laymen,  and  the  comparative 
simplicity  of  the  attendant  conditions  enables  us  to  form 
rapidly  a  correct  diagnosis. 

The  escape  of  blood  always  presupposes  a  solution  in  the 
continuity  of  the  blood  vessel  wall.  It  may  be  produced 
1,  by  locally  increased  blood  pressure  upon  the  otherwise 
normal  blood  vessel  walls  (Diapedesis,  Anastomosis)  ;  2,  by 
normal  blood  pressure  when  the  vascular  walls  have  become 
weakened  (Diaeresis,  Erosion,  Rhexis).  Hemorrhage  is  sub- 
ject to  certain  definite  laws,  i.  e.,  it  takes  place  when  and  as 
long  as  the  blood  pressure  within  the  softened  blood  vessel 
walls  is  more  powerful  than  the  resistance  which  the  escaping 
blood  meets  from  without.  The  amount  of  blood  lost  is 
limited  in  the  same  manner,  and  this  in  turn  determines  the 
fatality  or  non-fatality  of  the  hemorrhage. 

• 

I.  The  frequent  occurrence  of  hemorrhages  in  hypersemic 
affections  is  abundant  proof  that  the  mere  increase  of  lateral 
pressure  in  any  given  part  of  the  circulatory  apparatus  is 
enough  to  produce  rupture  and  hemorrhage.  The  capillary 
walls  are,  as  a  general  thing,  so  fragile  that  they  are  in  many 
cases  even  unable  to  withstand  either  inflammatory  or  con- 
gestive hypersemia. 

Under  these  circumstances,  the  blood  exudes  in  minute 
drops  through  fine  openings  in  the  capillary  wall.  This 
process  was  designated  diapedesis,  even  at  a  time  when  blood 
corpuscles  and  their  migration  were  not  dreamed  of.  We 
should  now  call  it  "  extravasation."  The  histological  details 
of  diapedesis  were  given  under  the  head  of  venous  hyper- 
semia,  which  section  I  would  recommend  for  re  -perusal.  The 
continuation  of  the  process  depends  upon  what  becomes  of  the 
blood  outside  the  capillary  wall.  In  a  thick,  unelastic  paren- 
chyma, like  that  of  the  brain,  the  extravasated  blood  forms  at 


the  point  of  rupture  a  small  round  drop  0.001  mm.  (^Vs  in.)  in 
diameter,  which  is  not  absorbed,  but  undergoes  instead  further 
metamorphoses.  (See  remarks  upon  capillary  hemorrhage 
in  my  Manual  of  Pathological  Histology). 

When  not  opposed  by  the  parenchyma,  the  blood  corpuscles 
spread  through  the  interstices  of  the  connective  tissue,  and 
penetrate  in  this  way  the  beginnings  of  the  lymphatics,  reach- 
ing also  the  neighboring  free  surfaces,  with  whose  secretions 
they  become  incorporated,  and  impart  to  the  same  a  hemor- 


108  GENERAL    PATHOLOGY. 

rhagic  character.  Such  hemorrhagic  secretions  are  particu- 
larly frequent  in  the  mucous  membranes  of  the  digestive  tract 
in  people  suffering  from  heart  disease,  where  the  induced  con- 
gested state  of  the  liver  backs  up  the  blood  in  the  radicles  of 
the  portal  vein,  finding  a  favorable  spot  for  diapedesis  in  the 
soft  and  superficial  venous  capillaries,  which  are,  in  reality, 
intended  for  the  purpose  of  absorption. 

The  bloody  stools  in  heart  and  liver  diseases  were  known 
to  Hippocrates  as  fislatva  x<>Xrj.  This  blood  discharge  per  rec- 
tum frequently  appears  black,  owing  to  the  changes  it  under- 
goes in  passing  through  the  intestines.  The  blood  which  is 
vomited  from  the  bottom  and  sides  of  carcinomatous  ulcers  of 
the  stomach  resembles  coffee-grounds,  because  the  blood  which 
extravasates  drop  by  drop  coagulates  immediately,  and  be- 
comes brown  under  the  action  of  the  acid  gastric  juice. 
•  Not  all  blood  corpuscles,  however,  are  absorbed  or  excreted. 
A  large  share  of  them  remain,  as  a  rule,  in  the  porous  paren- 
chyma, and  lead  to  the  formation  of  pigment-granules,  which, 
after  the  lapse  of  years,  still  remain  to  testify  of  the  extrava- 
sation. Many  are  of  a  rusty  color,  and  give  to  the  affected 
parts,  i.  e.,  membranes,  a  highly  characteristic,  yellowish-red, 
or  brownish-black  appearance.  Under  the  microscope,  we 
see  mostly  round  bodies  of  an  intense  yellow  color,  aggregated 
together  in  clusters  containing  from  three  to  ten,  and  attached 
t->  the  external  surface  of  the  blood  vessels,  whose  ramifica- 
tions they  follow.  The  detailed  observations  which  have  been 
made  of  late,  as  to  the  manner  in  which  these  clusters 
originate  from  the  extravasated  blood  corpuscles,  will  be 
found  recorded  in  my  Pathological  Histology.  According  to 
these  observations,  every  yellowish-red  body  corresponds  to  a 
number  of  former  red  blood  corpuscles  or  their  coloring 
matter.  Peroxide  of  iron  predominates  in  these  pigments 
above  all  other  chemicals. 

II.  The  second  form  of  hemorrhage  is  that,  where,  with 
normal  blood  pressure,  a  deep  mechanical  injury  to  the  body 
effects  a  solution  in  the  continuity  of  the  blood  vessel  wall 
(Diaeresis).  In  diceresis  we  have  to  consider,  apart  from  the 
calibre  of  the  blood  vessel,  and  the  existing  blood  pressure, 
the  rigidity  or  weakness  of  the  blood  vessel  wall,  its  con- 
tractility, and  the  manner  in  which  the  solution  of  continuity 
takes  place.  Incisions  into  large  arteries  are  extremely 


LOCAL    DERANGEMENTS.  109 

dangerous,  for,  although  the  arteries  may  contract  forcibly 
on  the  wound,  their  lumen  is,  nevertheless,  still  large  enough 
to  cause,  with  the  assistance  of  the  blood  pressure,  a  fatal 
escape  of  blood.  In  ruptures  of  the  medium-sized  and 
smaller  arteries,  the  highly-elastic  and  contractile  arterial 
walls  contract  upon  themselves,  and  close  the  lumen  in  most 
cases  so  effectually  that  the  hemorrhage  is  often  temporarily 
arrested.  I  have  seen,  repeatedly,  lacerations  of  the  axillary 
artery  where  no  great  amount  of  hemorrhage  occurred. 

Wounds  of  veins  are,  in  the  main,  less  dangerous,  providing 
they  do  not  occur  in  the  region  of  the  respiratory  apparatus, 
in  which  case  the  air  sucked  in  through  the  proximal  opening 
produces,  the  moment  it  reaches  the  heart  and  lungs,  imme- 
diate death.  Venous  wounds  are  only  dangerous  in  veins  of 
large  calibre,  and  in  those  which  possess  either  a  stiff,  unyield- 
ing wall,  or  are  attached  to  an  unyielding  parenchyma,  which 
cannot  collapse.  The  sinuses  of  the  dura  mater  and  the 
hepatic  veins  are  examples  of  such  blood  vessels.  Even 
lacerations  of  these,  as  well  as  of  the  blood  vessels  of  a 
fibroma  of  the  uterus,  are  extremely  serious,  on  account  of  the 
difficulty  in  checking  the  hemorrhage. 

Diabrosis  is  the  erosion  of  a  blood  vessel  by  a  destructive 
process  attacking  it  from  without.  It  occurs  chiefly  in  simple 
or  specific  ulcerations,  and  in  pulmonary  and  intestinal  ulcer- 
ations  growing  in  the  vicinity  of  a  large  artery.  The  wall  of 
the  blood  vessel  at  its  most  exposed  point  becomes  infiltrated 
in  the  same  manner  as  the  surrounding  connective  tissue. 
When  the  infiltration  has  reached  a  certain  stage,  the  support- 
ing connective  tissue  and  muscle  fibres  begin  to  dissolve,  and 
the  infiltrate,  which  is  composed  chiefly  of  round  cells,  is  no 
longer  able  to  resist  the  blood  pressure.  The  diseased  spot  is 
apt  first  to  protrude  a  little,  resembling  a  small,  pouch-like 
aneurism,  until  finally  the  blood  ruptures  the  vulnerable  point, 
and  its  flow,  even  in  smaller  vessels,  is  very  difficult  to  check. 
The  conditions  are  more  favorable  when  the  vessel  is  attacked  a 
fronte,  and  not  in  its  continuity — as  occasionally  occurs  in  gas- 
tric ulcers.  When  all  the  branches  of  a  blood  vessel  are  involved 
in  such  a  process  it  often  happens  that  the  entire  vessel  becomes 
thrombosed  up  to  its  origin,  and  if  erosion  occur  then,  there 
is  very  little  difference  between  it  and  a  lateral  rupture. 

We  now  reach  the  laceration  or  rupture  of  blood  vessels  in 
the  strict  sense  of  the  word,  i.  e.,  hemorrhage  by  rhexis.  Here 


110  GENERAL    PATHOLOGY. 

the  blood  vessel  wall  is  attacked,  weakened,  and  finally  broken 
down  by  an  internal  process  of  destruction.  Atheromatous 
degeneration  is  that  interesting  process  by  which  the  fatty 
degeneration  of  the  intima  gives  rise  to  a  slight  hemorrhage  of 
the  brain. 

All  cranial  arteries  are,  we  know,  provided  with  unusually 
thin  walls ;  the  closed  and  bony  cranium  furnishes,  with  the 
aid  of  the  intermediate  parenchyma,  a  sufficient  counter  pres- 
sure for  a  part  of  the  blood  pressure.  The  adventitia  is  here 
a  simple  connective-tissue  lamella.  The  muscular  coat  is 
lacking  in  the  elastic  fibres  which  give  to  the  remaining 
arteries  of  the  body  such  a  high  degree  of  elasticity  and  firm- 
ness. It  consists  only  of  transverse  rings  of  smooth,  muscular 
fibres,  joined  together  sparingly  by  structureless  connective 
tissue.  Its  tenacity  is  the  result  of  the  cumulative  resistance  of 
the  intima  which  covers  its  transverse  layers  uniformly.  The 
intima  itself  is  very  frail,  consisting,  at  the  artery  of  the  fissure 
of  Sylvius,  of  only  six  so-called  striated  lamellae,  while  other 
arteries  of  equal  calibre  have  at  least  fifteen.  It  is,  therefore, 
intelligible  that  a  process  like  fatty  degeneration  of  the  intima 
(not  to  be  confounded  with  atheromatous  degeneration,  which 
it  often  accompanies)  easily  leads,  in  the  blood  vessels  of  the 
brain,  to  a  complete  destruction  of  the  entire  membrane,  and 
threatens  the  integrity  of  the  blood  vessel  wall,  while  in  the 
aorta  the  same  process  only  produces  superficial  inequalities 
of  no  clinical  value.  If  a  passing  or  perhaps  trifling  congestion 
of  the  brain  should  now  set  in — the  result,  probably,  of  an  in- 
toxicating drink,  of  prolonged  and  violent  expiration,  of  strain- 
ing at  stool,  of  screaming,  coughing,  etc. — the  blood  perforates 
the  degenerated  intiraa,  forces  the  transverse  bundles  of  the 
media  apart,  and  ruptures  the  slight  and  unresisting  adventitia. 

The  above-described  hemorrhage  of  the  brain  occurs  in  the 
larger  branches  of  the  artery  of  the  fissure  of  Sylvius.  In  the 
smaller  branches  of  the  same  trunk,  especially  in  their  anas- 
tomosing branches,  it  may  happen  that  only  the  intima  and 
media  are  ruptured,  and  the  distended  adventitia  is  elastic 
enough  to  retain  the  extravasated  blood  until  the  counter- 
pressure  from  without  checks  the  further  escape  of  blood 
(dissecting  aneurism).  Rhexis  also  occurs  in  the  capillaries, 
and  leads  to  the  formation  of  foci,  varying  in  size  from  a 
pea  to  a  walnut,  wherein  the  parenchyma  is  dotted  with 
numerous  distinct  blood  points. 


LOCAL   DERANGEMENTS.  Ill 

In  proportion  to  the  calibre  of  the  bleeding  vessel  is  the 
danger  of  a  rapid  and  excessive  loss  of  blood,  which  may 
result  either  in  the  death  of  the  individual,  or  in  the  destruc- 
tion of  the  parenchyma,  which  is  flooded,  as  the  result  of 
strong  arterial  pressure,  with  a  large  amount  of  blood. 

In  case  such  hemorrhagic  infarcts  (Hsematomata)  do  not 
prove  instantly  fatal,  the  products  of  hemorrhage  may  be 
gradually  re-absorbed,  and  a  partial  restoration  of  the  injured 
part  be  effected.  This  happens  also  in  pigmentation,  so  that, 
years  afterwards,  yellowish  or  brownish  marks  recall  the 
original  lesion.  In  such  situations,  besides  other  amorphous 
pigments,  crystallized  "  hsematoidin "  is  often  found,  which 
has  latterly  been  proved  to  be  identical  with  the  bilirubin  of 
normal  bile.  The  granular  pigments  are  composed  almost 
entirely  of  peroxide  of  iron. 

GANGRENE. 

It  has  been  customary  to  designate  one  of  the  sub-orders 
of  local  death  (Necrosis,  p.  93),  as  gangrene.  When  the 
dead  part  becomes  very  plentifully  or  excessively  filled 
with  blood,  it  soon  receives  from  the  action  of  the  putrescent 
blood  a  diffuse  coloring,  shading  from  dark  to  black.  The 
comparison  with  the  "  carbonizing "  process  is,  therefore,  not 
inappropriate. 

The  blood  putrefies  rapidly.  The  first  sign  of  incipient 
decomposition  is  the  diffusion  of  the  coloring  matter  from 
the  red  blood  corpuscles.  First  the  serum  becomes  colored, 
then  the  vessel  walls,  and  finally  all  the  surrounding  tissues 
within  the  limits  of  the  dead  parts.  A  bluish,  livid  color- 
ation is  visible  through  the  epidermis,  until  the  latter  is 
lost,  and  the  dark  red  color  of  the  putrescent  blood  is  plainly 
seen.  If  dessication  is  prevented,  the  color  becomes  greenish, 
which  finally  passes  into  the  grayish-green  of  decomposition, 
accompanied  by  an  offensive  odor  (Moist  gangrene,  spha- 
celus).  If  after  the  removal  of  the  epidermis,  evaporation  is 
not  prevented,  the  atrophied  part  dries  up  into  a  dark  mass, 
which  in  reality  resembles  coal  (Dry  gangrene,  mummi- 
fication). 

Among  the  local  disturbances  of  circulation  we  find  embo- 
lism (pp.  72,  102),  frequently  leading  to  gangrene;  also  the 
strangulation  of  a  part  (p.  104)  when  all  the  veins  are  com- 
pressed; also,  all  inflammatory  processes,  in  which  the  in- 


112  GENERAL  PATHOLOGY. 

flammatory  retardation  of  the  blood  terminates  in  complete 
stasis.  An  abnormal  condition  of  the  blood  vessel  apparatus 
is  always  responsible  for  this  unfavorable  result.  In  old  men 
and  women,  the  arteries  are  often  hardened  and  calcified, 
and  consequently  incapable  of  that  arterial  congestion  which 
is  indispensable  to  the  removal  of  passive  hypersemia.  In 
other  instances,  the  capillaries  themselves  are  so  altered  by 
the  inflammatory  irritation  (for  instance,  cold)  that  the  adhe- 
sion of  the  blood  to  the  capillary  wall  overbalances  the  motive 
power  of  the  heart,  and  the  blood  "sticks,"  literally  speaking, 
in  the  capillaries.  All  cases  of  gangrene  are  attributable  to 
one  or  the  other  of  the  above  causes.  As  the  relation  of  the 
gangrenous  part  to  the  general  organism  is  determined  by 
the  rules  laid  down  under  the  head  of  cicatrization  and 
sequestration,  no  recapitulation  is  necessary. 

GENERAL  DISTURBANCES. 

THE   HEART. 

Preliminary  Remarks. — The  pathological  anatomy  of  the 
heart  shows  us  numerous  instances  of  disease,  in  which  the 
normal  functions  of  the  heart  are  impeded.  The  most  im- 
portant of  these  may  be  briefly  mentioned  as  follows: — 

Acute  Endocarditis  leads  to  an  inflammatory  swelling  of 
the  mitral  or  aortic  valve,  resulting,  it  may  be,  in  the  perfora- 
tion and  carrying  away  in  fragments  of  the  same.  Chronic 
Endocarditis  is  a  new  formation  of  hyperplastic,  indurated, 
connective  tissue,  by  which  the  leaflets  are,  first  of  all,  thick- 
ened; then  follow  contraction,  rigidity,  and  even  calcification. 
Not  infrequently  the  diseased  leaflets  become  adherent  to 
each  other.  The  valves,  being  now  perforated,  disintegrated 
and  retracted,  can,  at  the  time  when  they  should  most  offer  resist- 
ance to  the  reflux  of  the  blood,  no  longer  do  so,  but  permit, 
instead,  regurgitation ;  and,  being  thickened,  rigid  and  ad- 
herent, present  a  constricted  aperture  to  the  outflowing  blood, 
when  normally  they  should  be  closely  pressed  against  the 
walls  of  the  heart.  Stenosis,  therefore,  resembles  insufficiency 
in  its  effects,  inasmuch  as  it  impedes  the  flow  of  blood  through 
the  diseased  part. 

Chronic  Myocarditis  is  a  new  formation  of  hyperplastic,  in- 
durated, connective  tissue,  which  produces  atrophy  of  the 
muscular  structure  of  the  heart,  and  the  so-called  "fibroid 


GENERAL   DISTURBANCES.  '113 

patch  "  and  partial  aneurism  upon  the  anterior  wall  of  the  left 
ventricle.  With  the  loss  of  muscular  structure,  comes  a  cor- 
responding diminution  of  muscular  power.  Similar  effects 
are  produced  by  all  diffused  and  circumscribed  degenerations 
of  the  muscular  structure  of  the  heart :  brown  atrophy,  in 
aged  and  debilitated  persons,  fatty  degeneration,  fatty  infiltra- 
tion, abscess  of  the  heart,  and  tumors,  embolism  of  the  coro- 
nary arteries,  etc.  The  functional  exhaustion  of  the  heart, 
which,  after  severe  and  protracted  fevers,  brings  about  the 
lethal  result,  is  not  always  accompanied  by  visible  anatomical 
changes  in  the  muscular  substance. 

In  Pericarditis  the  diastole  of  the  heart  is  obstructed  by 
the  accumulation  of  free  exudate  in  the  pericardium.  If 
adhesions  between  the  pericardial  layers  ensue,  the  systole  is 
impeded.  Serous  and  hemorrhagic  effusions  into  the  pericar- 
dium, as  well  as  the  rare  pericardial  sarcomata,  also  prevent 
the  normal  expansion  of  the  heart.  So  also  do  all  those  large 
tumors  of  the  mediastinum,  which  exert  mechanical  pressure. 

However  varied  and  more  or  less  intelligible  these  changes 
may  be,  their  influence  upon  the  circulation  culminates  in  a 
single  point,  viz.,  the  defective  movement  of  the  blood  at  the 
centre  of  the  circulatory  apparatus ;  in  other  words,  weakness 
of  the  heart.  This  lessens  and  almost  equalizes  the  difference 
in  pressure  otherwise  existing  between  the  arteries  and  veins — 
that  difference  which  forces  the  arterial  blood  through  the 
capillaries  into  the  veins.  The  veins  now  become  engorged, 
and  the  arteries  more  and  more  bloodless.  The  same  effect 
upon  the  general  circulation  is,  of  course,  produced  by  any 
obstacle,  situated  external  to  the  heart  in  either  of  the  main 
arterial  trunks,  which  by  exhausting  the  impetus  of  the  blood, 
depreciates  the  work  of  the  heart ;  always  providing  that  the 
entire  transverse  calibre  of  the  bloodvessel  be  thus  obstructed. 
Under  this  head  are  included  changes  in  the  aorta  and  the 
pulmonary  artery. 

Chronic  endarteritis  causes  sclerotic  thickening  of  the 
intima,  which  leads  either  through  fatty  degeneration  to  the 
atheromatous  abscesses  and  ulcers,  or  through  calcification  to 
so-called  "  ossification  of  arteries."  By  all  of  these  the  fric- 
tion of  the  blood  against  the  arterial  wall  is  heightened  and 
it  simpetus  lessened.  The  same  effect  is  noted  in  calcification 
of  the  muscular  middle  coat,  which  occurs  simultaneously  in 
all  medium-sized  branches  of  the  aorta.  The  general  disten- 


114*  GENERAL    PATHOLOGY. 

tion  of  the  aorta,  as  well  as  the  circumscribed  dilatations  known 
as  aneurisms,  which  are  usually  the  result  of  endarteritis,  ob- 
struct the  general  circulation  in  two  ways  :  First,  on  account 
of  the  great  amount  of  blood  which  they  require  to  fill  them, 
and  in  a  measure  withdraw,  from  the  circulation ;  and,  sec- 
ondly and  chiefly,  on  account  of  the  increased  motive  power 
necessary  to  propel  the  surplus  of  arterial  blood  through  them. 

In  pulmonary  emphysema  most  of  the  small  branches  of  the 
pulmonary  artery  become  obliterated.  Pleuritic  effusions 
occasionally  exert  upon  the  entire  lung,  including  the  terri- 
tory of  the  pulmonary  artery,  abnormal  pressure,  which  is 
detrimental  to  the  return  of  blood  into  the  left  auricle. 

Leaving  these  preliminaries,  we  will  now  pass  to  the  consid- 
eration of  those  complicated  symptoms  which  result  from 
disturbances  of  the  heart  or  equivalent  conditions.  We  will 
begin  with  the  phenomena  which  accompany  a  sudden  decrease 
or  failure  in  the  action  of  the  heart. 

A.     Sudden  Decrease  or  Failure  in  the  Action  of  the  Heart. 

a.    Death  from  Heart  Failure. — Signs  of  Death. 

The  immediate  result  of  a  definite  suspension  of  the  heart's 
action  is  death.  To  ascertain  with  certainty  the  death  of 
an  individual,  we  first  feel  for  the  radial  artery,  then  place 
our  hand  in  the  neighborhood  of  the  apex  beat  of  the  heart, 
and  finding  no  impulse  here,  await  the  appearance  of  those 
phenomena  which  mark  the  gradual  equalization  of  pressure 
between  the  arteries  and  veins.  The  first  of  these  is  the  cessa- 
tion of  movement  of  the  blood  in  the  capillaries,  followed  by 
the  almost  complete  emptying  of  their  contents,  their  elastic 
tension  being  no  longer  overcome  by  the  blood  pressure. 
Other  signs  of  death  are  pallor  of  the  skin  and  the  sinking 
in  of  the  eye,  i.  e.,  the  collapse  of  the  contents  of  the  orbit, 
together  with  the  eyeball  itself.  The  eyelids  remain  open, 
and  it  is  necessary  to  draw  them  down  over  the  pupil.  All 
the  prominent  bodily  features  become  sharply  defined,  as,  for 
instance,  the  nose,  chin,  jaw,  and  condyles  of  the  joints. 

As  the  pallor  increases,  the  peripheral  parts  gradually  be- 
come cold.  The  latter  attacking  first  the  hands  and  feet, 
nose,  lips  and  chin,  travels  to  the  centre  of  the  body,  which 
retains  its  warmth,  according  to  circumstances,  from  twelve 
to  twenty  hours. 


GENERAL    DISTURBANCES.  115 

The  blood  has  in  the  meantime  massed  itself  in  the  trunk 
and  main  branches  of  the  vena  cava  and  in  the  heart.  The 
right  auricle  is  greatly  engorged,  the  right  ventricle  less  so. 
In  consequence  of  the  higher  temperature  retained  here  for 
some  time,  and  the  associated  prolonged  vitality  of  the  heart 
wall,  the  blood  coagulates  very  gradually,  and  the  blood 
corpuscles  have  time  to  sink,  by  virtue  of  their  specific 
gravity,  to  the  bottom  of  the  liquor  sanguinis,  leaving  above 
them  'a  considerable  zone  of  clear  yellow  fluid,  which, 
after  coagulation,  leads  to  the  formation  of  the  gelatinous 
buffy  coat. 

Another  link  in  the  chain  of  post-mortem  blood  changes  is 
the  appearance  of  discolorations  (livores  mortis).  The  blood 
being  a  heavy  fluid  seeks  the  lowest  level,  just  as  soon  as  the 
heart  ceases  to  oppose  this  tendency.  At  death  the  sinking 
occurs  throughout  the  general  circulation.  Livid  purple 
spots  appear  in  the  dependent  portions  of  the  body,  which 
present  at  their  borders  the  appearance  of  discolored  marble. 

A  greenish  discoloration  starting  in  the  abdomen  and  jugu- 
lar regions  must  not  be  confounded  with  the  livores  mortis. 
The  former  is  indicative  of  approaching  decomposition,  and 
begins  in  the  contents  of  the  ileum,  which  are  abundantly 
infiltrated  with  bacteria. 

Respiration  does  not  always  cease  with  the  beats  of  the 
heart.  Often  single  deep  inspirations  occur  after  the  heart 
is  entirely  motionless.  In  rare  instances  the  respiration  is 
prolonged  for  some  minutes,  and  this  tenacity  of  the  respi- 
ratory apparatus  may  often  bridge  over  short  intermissions  in 
the  action  of  the  heart,  as  the  aspiration  and  expulsion  of  the 
blood  by  the  lungs  is  an  important  addition  to  the  mechanical 
power  of  the  circulation.  Upon  this  circumstance  are  based 
the  customary  efforts  at  resuscitation  by  artificial  respiration, 
which  are  often  followed  by  astonishing  results. 

The  loss  of  sensibility  and  motility  are  the  least  reliable 
among  post-mortem  symptoms.  These  are  only  criteria  after 
the  muscular  structures  become  perfectly  hard  and  stiff,  which 
is  usually  coincident  with  complete  coldness  of  the  body. 
The  rigor  mortis  of  individual  groups  of  muscles  may,  upon 
occasion,  be  overcome,  but  never  that  of  the  entire  muscular 
system. 


116  GENERAL   PATHOLOGY. 

/?.   Collapse. 

Another  group  of  symptoms  which  often  terminates  fatally, 
proceed  from  a  weakening  of  the  heart's  action,  which  is  so 
sudden  and  decided  that  the  arterial  pressure  no  longer 
suffices  to  sustain  general  circulation.  Pulsation  in  the  radial 
artery  and  in  the  heart  may  possibly  be  felt,  but  it  is  extreme- 
ly feeble.  Capillary  circulation  is  arrested  at  the  periphery 
of  the  body.  The  hands  and  feet,  and  even  the  nose  and  ears, 
become  cold.  The  skin  becomes  pale  and  lifeless,  and  adheres 
closely,  as  in  death,  to  the  underlying  parts,  the  condyles 
become  prominent,  the  lips  recede  from  the  teeth,  the  eyelids 
from  the  eyeballs,  and  the  jaw  drops  (Facies  Hippocratica). 
Collapse  is  generally  sudden  and  calls  for  vigorous  measures, 
the  use  of  stimulants,  friction,  etc.,  in  order  to  restore  the 
suspended  activity  of  the  heart,  and  avert  a  fatal  result. 

Y.  Hypostatic  Congestion  and  (Edema  of  the  Lungs.  Apoplexy  and  Paralysis  of  the  Lungs. 

If  after  a  long  and  exhausting  illness  the  heart  is  no  longer 
able  to  contract  properly  and  force  the  blood  into  the  lungs,  it 
by  no  means  follows  that  the  important  influence  exerted  by 
inspiration  upon  the  thoracic  circulation  is  removed.  Every 
breath  that  is  drawn  sends  fresh  amounts  of  venous  blood 
through  the  right  heart  into  the  pulmonary  vessels,  where,  by 
the  effective  operation  of  the  valves  of  the  pulmonary  artery, 
and  its  well-known  power  of  resistance,  not  a  single  drop  of  the 
aerated  blood  returns  into  the  right  heart.  The  consequences 
are  self-evident.  Following  the  law  of  gravity,  the  blood  sinks 
into  the  most  dependent  parts  of  the  lungs,  filling  them  to  en- 
gorgement (hypostatic  congestion).  The  momentum  of  the 
blood  steadily  decreases  and  lateral  pressure  is  increased,  until 
a  mechanical  infiltration  of  the  liquor  sanguinis  is  inevitable. 
The  transudate  which,  from  the  admixture  of  red  blood  cor- 
puscles, is  of  a  light  red  color,  appears  on  one  side  in  the 
pleural  cavity,  on  the  other  into  the  alveoli  of  the  lung.  In 
the  latter  the  presence  of  air  is  revealed  upon  auscultation,  by 
crackling  rales.  After  the  air  is  excluded  there  is  a  flat  per- 
cussion note,  by  which  the  height  of  the  oedema  can  be  deter- 
mined with  exactitude.  When  about  one-half  of  the  respir- 
atory tract  is  thus  affected,  life  usually  passes  away  with  a  few 
deep  inspirations. 

Lesser  degrees  of  hypostatic  congestion  appear  as  inter- 
current  symptoms ;  these  either  disappear,  or  form  the  basis 


GENERAL   DISTURBANCES.  117 

of  a  future  inflammatory  affection  of  the  lung.  There  is, 
doubtless,  a  slight  degree  of  local  hypostatic  congestion  in 
even  an  ordinary  pneumonia,  as  it  is  impossible  to  imagine  a 
large  accumulation  of  blood  in  the  lungs  which  would  not  be 
more  or  less  affected  in  its  distribution  by  the  laws  of  gravity. 

B.     Gradual  Weakening  of  the  Heart's  Action. 

The  great  number  and  complexity  of  the  symptoms  accom- 
panying the  gradual  weakening  of  the  function  of  the  heart 
are  due  to  the  fact  that  the  heart,  more  than  any  other  organ, 
is  able  by  its  own  action  to  neutralize  the  effects  of  unusual 
and  abnormal  disturbances.  By  its  function  and  nutrition  it 
is  essentially  adapted  to  cope  with  the  most  varied  abnormal 
conditions.  Thus  we  see,  side  by  side  with  the  symptoms  of 
functional  weakness,  the  phenomena  of  equalization,  which 
often  bring  about  complete  compensation  for  the  existing 
defect.  This  compensation,  although  not  permanent,  often 
exists  for  a  long  time. 

ot.    Compensatory  Symptoms. 

As  it  is  universally  conceded  that  it  is  the  province  of  the 
heart  to  maintain,  by  its  contractions,  normal  blood  pressure 
in  the  systemic  and  pulmonary  circulations,  it  is  evident  that 
an  accelerated  heart  beat  will  constitute  one  of  the  symptoms 
under  discussion.  The  blood  pressure  in  the  aorta  and  pul- 
monary artery  is  directly  increased  by  this  acceleration. 
Palpitation,  therefore,  is  one  of  the  first  and  persistent  signs 
of  impaired  activity  of  the  heart.  Important,  also,  is  simple 
hypertrophy  of  the  myocardium,  where  the  heart  performs 
an  excessive  and  abnormal  amount  of  work.  In  chronic 
endarteritis,  the  orifice  of  the  aorta  is  occasionally  so  con- 
tracted that  one  can  scarcely  determine  through  what  crevice 
or  imperceptible  aperture  the  blood  passes  into  the  aorta,  and 
yet,  by  the  powerful  hypertrophy  of  the  left  ventricle,  the 
heart  is  able  to  force  through  continually  the  requisite  supply. 
The  same  process  is  repeated  in  stenosis  of  the  right  and  left 
auriculo-ventricular  valves,  although  there  are  here  auxiliary 
forces  at  work. 

The  direct  consequence  of  every  obstruction  of  the  blood 
paths  is  naturally  an  aggregation  of  blood  at  the  point  of 
obstruction,  and  a  corresponding  increase  of  pressure  in  the 
affected  portion  of  the  circulatory  apparatus.  Increased  pres- 
sure leads  to  increased  dilatation  and  tension  of  the  blood 


118  GENERAL   PATHOLOGY. 

vessel  wall.  If,  by  reason  of  an  insurmountable  obstacle,  the 
blood  cannot  regurgitate,  it  is  plain  that  the  heightened  ten- 
sion of  the  blood  vessel  walls  in  the  dilated  territory  will 
give  a  favorable  impetus  to  the  forward  movement  of  the 
blood.  This  is  a  decisive  factor  in  the  compensation  arising 
from  a  defective  mitral  valve.  The  heightened  tension  of  the 
pulmonary  circulation  finds  an  excellent  point  of  support  in 
the  closely-shutting  valve  system  of  the  pulmonary  artery, 
and  its  beneficial  effects  are  apparent  even  in  view  of  its 
serious  concomitants,  viz.,  hypersemia  of  the  lungs,  dilatation 
of  the  capillaries,  brown  induration,  and  the  danger  of  hemor- 
rhagic  infarcts,  not  to  mention  the  constant  and  annoying 
bronchial  catarrh.  The  healthy  mitral  valve  is  also  a  firm 
point  of  support  for  the  development  of  a  compensatory  dila- 
tation of  the  left  ventricle,  in  cases  of  defect  of  the  aortic 
valves.  Without  this,  the  existing  muscular  hypertrophy 
would  be  insufficient  to  supply  the  aorta  with  blood,  especially 
when,  on  account  of  an  insufficiency  of  the  valve,  there  is  a 
certain  diastolic  regurgitation  of  aortic  blood.  This,  however, 
implies  that  the  dilatation  be  retained  within  certain  limits, 
which,  if  overstepped,  would  shut  off  the  possibility  of  a 
perfect  systolic  contraction,  and  thus  destroy  compensation. 

The  tricuspid  valve  is  unquestionably  the  weakest  valve  of 
the  heart.  If,  therefore,  the  right  ventricle  be  distended  with 
blood  from  the  lungs,  or  from  any  other  source,  its  hypertro- 
phy will  immediately  ensue.  Although  equally  prompt,  this 
hypertrophy  is  never  as  powerful  and  beneficial  as  that  pro- 
duced in  the  left  ventricle  by  stenosis  of  the  aorta,  because  the 
dilatation  of  the  ventricle  is  followed  immediately  by  such  an 
extension  of  the  right  auriculo-ventricular  valve  that  the  tips 
of  the  tricuspid  valve  are  unable  to  fill  in  the  intervening  space. 
Thus  is  produced  that  momentous  condition  of  relative  insuffi- 
ciency of  the  tricuspid,  which  so  often  proves  the  fatal  element 
in  heart  disease;  the  blood  is  projected  directly  into  the  venous 
system,  and  finds  in  its  broad  paths  not  a  single  point  of  support 
where  an  effective  equalizing  tension  might  be  established. 

y9.   Cyanosis  and  Dropsy. 

We  have  indicated  above  that  the  compensatory  power  of 
the  circulatory  apparatus  may  oppose  the  impending  decrease 
of  arterial  pressure,  up  to  a  certain  point.  When  this  point 
is  temporarily  or  permanently  overstepped,  compensation  be- 


GENERAL    DISTURBANCES.  119 

comes  imperfect,  and  the  abnormal  accumulation  of  blood  in 
the  venous  system  manifests  itself  equally  in  two  diseased 
phenomena,  viz. :  Cyanosis  and  Dropsy. 

Cyanosis  in  its  lightest  form  is  apparent  as  a  marked  injec- 
tion of  the  superficial  veins  at  the  periphery  of  the  systemic 
circulation.  The  ears,  nose,  lips,  cheeks  and  chin  are  over- 
spread with  a  bluish  discoloration.  In  continued  cyanosis 
the  capillaries  protrude  more  and  more,  in  the  shape  of  delicate, 
convoluted,  stellated  figures,  which  appear  to  lie  immediately 
under  the  epithelium.  The  cuticle  of  the  arms  and  legs  is 
similarly  affected,  but  here  the  subcutaneous  veins  are  espe- 
cially prominent  and  abnormally  engorged.  The  sinuous 
course  of  these  veins,  which  in  the  normal  body  are  visible 
through  the  integument,  becomes  now  more  sharply  defined, 
and  finally  terminates  in  knotty  dilatations,  known  as  varicose 
veins. 

The  engorgement  of  the  venous  system  leads,  sooner  or  later, 
to  the  much  dreaded  extravasation  of  blood  serum  from  the 
dilated  vessels,  which  we  call  dropsy*  (hydrops).  This  effu- 
sion, being  serum  mechanically  pressed  out,  is  called  a  transu- 
date,  as  opposed  to  exudate,  whose  inflammatory  nature  in- 
volves the  tissue  in  active  participation. 

The  dropsical  fluid  is  either  colorless,  clear  or  pale  yellow, 
alkaline,  and  possessing  an  insipid,  salty  taste.  It  consists  of 
from  92  per  cent,  to  95  per  cent,  of  water  (although  it  may 
contain  99  per  cent.)  and  of  albumen  ;  the  latter  being  less 
abundant  than  that  contained  in  the  blood  serum.  This  varies, 
however,  with  the  age  of  the  transudate,  which  becomes  more 
albuminous  as  the  dropsical  condition  is  prolonged.  It  is  not 
unlikely  that  certain  chemical  changes  take  place,  such  as  the 
conversion  of  the  sero-albumen  into  a  peptone,  resembling 
that  produced  in  digestion.  The  presence  in  the  transudate 
of  the  more  easily  diffusible,  extractive  matters  of  the  blood 
of  urea,  for  instance,  is  a  priori  to  be  expected.  It  is 
likely  that  other  constituents  of  the  transudate,  as,  for  ex- 
ample, fat  and  mucus,  have  been  formed  like  the  albuminous 
peptones,  by  secondary  changes. 

The  external  phenomena  of  dropsy  proceed  so  directly  and 

*  The  term  oedema  is  applied  to  a  dropsical  parenchyma  (from  otdsca, 
to  swell) ;  a  dropsical  cavity  is  termed  hydrops.  Anasarca  (general 
dropsy)  is  an  oedema  of  the  skin  and  areolar  tissues.  Ascites  is  a 
dropsy  of  the  peritoneum. 


120  GENERAL,   PATHOLOGY. 

simply  from  the  effects  of  mechanical  infiltration,  that  they 
can  be  easily  reproduced  by  artificial  injection  of  the  parts 
with  a  salt  solution.  It  is  a  well-known  axiom  that  among 
stereometric  bodies  the  sphere  embraces  within  the  smallest 
circumference  the  largest  amount  of  space.  When,  therefore, 
a  cavity  is  forced  to  receive  and  surround  the  largest  possible 
volume  of  fluid,  it  assumes  naturally,  whatever  its  previous 
shape  might  have  been,  that  of  the  sphere.  This  tendency 
manifests  itself  strikingly  in  severe  forms  of  dropsy  of  the 
abdomen  (ascites).  The  characteristic  sign  produced  by  gently 
tapping  (percussion)  with  the  finger  such  an  accumulation  of 
fluid  is  an  important  diagnostic  symptom.  A  concentrically 
spreading  fluctuation  is  perceptible,  and,  upon  increasing  the 
tension  of  the  wall,  a  similar  short  vibration  of  the  latter  is 
felt. 

Parts  especially  rich  in  coarse  connective  tissue,  become, 
when  oedematous,  greatly  disfigured,  viz.,  the  eyelids,  prepuce, 
scrotum.  The  folds  of  soft  skin  which  characterize  these 
parts  are  replaced  by  round,  pouch-like  masses,  of  a  smooth, 
lustrous,  sometimes  transparent,  appearance,  which,  however, 
hang  heavily  and  are  inelastic  and  doughy  to  the  touch. 
The  impress  of  the  finger  remains  for  some  time  in  the  cold, 
waxy  surface. 

When  the  skin  is  stretched  to  its  utmost  capacity,  the 
texture  gradually  gives  way,  exhibiting  a  system  of  uniform 
water  lines,  which  show  us  that  the  normal,  invisible  texture 
of  the  skin  is  really  composed  of  individual  territories  of 
nutrition.  The  skin  may  at  last  burst  and  discharge  the 
dropsical  fluid.  Notwithstanding  the  excessive  abnormality 
of  this  condition,  it  may  be  compatible  for  a  long  period  with 
the  maintenance  of  life,  and  under  favorable  circumstances 
the  fluid  can  be  very  readily  absorbed.  This  can  be  easily 
shown  by  taking  a  piece  of  excessively  oedematous  skin,  and 
noting  with  what  ease  it  can  be  restored  to  its  original 
condition  by  merely  pressing  out  of  it  the  serous  fluid. 

In  a  gradual  weakening  of  the  function  of  the  heart,  cyanosis 
and  dropsy  furnish  criteria  for  determining  the  gravity  of  the 
situation  during  the  equalization  of  pressure  between  the 
arterial  and  venous  systems.  Death  results  usually  from 
over  dilatation  and  paralysis  of  the  myocardium,  occasionally 
also  from  paralysis  of  the  lung. 


DISTURBANCES    IN   THE    FORMATION   OF    BLOOD.         121 

III.  DISTURBANCES  IN  BLOOD-FORMATION. 

All  the  nutritive  matter  which  the  various  organs  of  the 
body  demand  and  consume  is  supplied  to  them  by  the  blood. 
The  most  important  of  these,  i.  e.,  oxygen  and  fat,  are  only 
temporary  constituents  of  the  blood,  since  they  are  only  taken 
up  in  the  alimentary  canal  and  lungs  in  order  to  be  again 
given  off  to  other  organs.  The  same  is  true  in  part  of  albu- 
men, although  this  does  not  hinder  us  from  considering  it  as 
one  of  the  integral  constituents  of  the  blood,  and  its  regular 
supply  as  one  of  the  chief  factors  in  the  normal  production  of 
blood.  The  more  permanent  or  so-called  tissue  constituents 
of  the  blood,  the  blood  corpuscles  and  the  liquor  sanguiuis,  de- 
pend also  so  largely  upon  these  temporary  substances  for  their 
duration  and  constant  renewal  that  we  cannot  fail  to  regard 
the  reception  of  such  substances  as  the  basis  of  normal  forma- 
tion of  blood. 

We  shall,  accordingly,  designate  as  disturbances  of  blood 
formation  (1)  the  insufficient  supply  of  nutritive  matter  from 
the  intestinal  tract;  (2)  the  insufficient  restoration  of  the 
constituents  of  the  blood  by  means  of  the  "  blood  making 
organs,"  i.  e.,  the  bone  marrow,  spleen  and  lymphatic  glands. 

DISTURBANCES     IN     THE     NUTRITION     SUPPLIED     BY     THE 
INTESTINAL   TRACT. 

The  pathological  changes  in  the  digestive  apparatus,  which 
bring  about  disturbances  of  the  nutrition,  are  both  numerous 
and  varied. 

Among  the  diseases  of  the  organs  of  mastication  and  deglu- 
tition, we  will  only  mention  stricture  of  the  oesophagus,  which, 
be  it  cicatricial  (sulphuric  acidj  or  carcinomatous,  renders  the 
passage  of  food  to  the  stomach  impossible. 

Among  stomachic  troubles,  catarrhal  gastritis  holds  the 
foremost  place,  appearing  either  as  an  independent  disease 
(injurious  ingesta,  drinking  cold  water,  when  the  body  is 
heated),  or  as  the  concomitant  of  more  serious  complications 
(fevers,  serious  affections  of  the  digestive  tract,  etc.) 

It  is  undoubtedly  true  that  there  is  an  insufficient  secretion 
of  gastric  juice  in  gastritis ;  and,  when  fever  is  present,  also 
a  lack  of  muriatic  acid.  This  also  would  suffice  to  disturb 
the  processes  of  solution  and  subsequent  resorption  of  the 
nutritive  material,  without  taking  into  account  that  the  muscu- 
9 


122  GENERAL   PATHOLOGY. 

lar  coat  of  the  stomach  is  so  far  involved  in  the  hyperaemia 
and  swelling  of  the  mucous  membrane  as  to  be  unable  to 
contract  with  vigor  and  purpose.  The  peristaltic  action  of 
the  stomach  becomes  imperfect  and  painful,  so  that  the  gastric 
juice  is  not  properly  mingled  with  the  food.  This  feature  is 
intensified  in  proportion  as  the  food  is  surrounded  by  a  hard 
exterior  or  by  difficultly  soluble  fats,  which  render  it  less 
permeable  to  the  gastric  fluid.  Digestion  is  furthermore 
impaired  by  the  copious  secretion  of  catarrhal  products,  which 
by  their  own  alkalinity  neutralize  and  render  inefficacious  a 
portion  of  the  acid  gastric  juice. 

In  conclusion,  therefore,  in  catarrhal  gastritis  a  large  share 
of  the  contents  of  the  stomach — albumen,  carbo-hydrates 
and  fat — remain  undissolved.  Such  a  condition,  it  is  clear, 
must  initiate  another  series  of  disturbances,  which  not  only 
still  further  compromise  the  digestive  functions,  but  also 
inaugurate  very  serious  dangers  of  another  kind.  Leaving  the 
effects  of  the  gastric  acid  to  a  certain  degree  out  of  the 
question,  we  find  that  the  undigested  ingesta  are  now  in  a 
condition  to  begin  individual  processes  of  fermentation  and 
even  decomposition.  These  soon  set  in,  as  the  necessary 
temperature,  moisture,  and  other  promoters  of  fermentation, 
are  all  at  hand.  There  is  no  lack  of  ordinary  yeast  cells ; 
these  latter  are  not  rarely  accompanied  by  small,  quadripartite 
cubes,  known  as  sarcina.  Under  their  influence  lactic  and 
carbonic  acids  and  hydrogen  are  produced.  There  is  a  feeling 
of  oppression,  heart  burn,  and  water  brash,  which  is  especially 
characteristic  of  a  disordered  stomach.  The  stomach,  in  par- 
ticular, becomes  gradually  dilated  as  the  result  of  gaseous 
fermentation.  At  this  stage  the  disorder  undergoes  a  decided 
change  for  the  worse. 

We  noticed  above  how  the  contractility  of  the  muscular 
coat  of  the  stomach  is  impaired  by  the  concomitant  hyper- 
semia  and  cedema.  No  sooner  is  there  a  positive  counter- 
pressure  established  in  the  stomach,  than  the  contractility  is 
completely  overcome,  and  there  follows  a  gradual  dilatation 
of  the  organ,  which  assumes  a  more  permanent  character, 
as  "  gastrectasis,"  and  presents  an  independent  chain  of 
symptoms.  Every  stomach  must  yield  to  gastrectasis,  if  its 
peristaltic  action  is  not  equal  to  the  demands  made  upon  it. 
We  may  also  expect  this  condition,  when  there  exists  in  the 
pylorus  any  mechanical  hindrance  to  the  emptying  of  the 


DISTURBANCES    IN   THE   FORMATION    OF   BLOOD.         123 

organ ;  such,  for  example,  as  a  strongly  protruding  or  a 
circular  constricting  carcinoma.  In  this  case  gastrectasis  is 
the  first  result  of  the  primary  affection  from  which  there  is 
developed  in  reversed  order,  as  in  catarrhal  gastritis,  first 
stagnation,  then  decomposition  of  the  contents,  and  lastly 
catarrhal  inflammation  and  disordered  secretion. 

Gastrectasis  is  furthermore  entitled  to  be  classed  among 
independent  diseases,  inasmuch  as  it  grows  from  causes  within 
itself,  finally  threatening,  even  the  life  of  the  individual. 
The  liquid  and  solid  products  gravitate  naturally  to  the 
bottom  of  the  stomach  into  the  greater  curvature,  and  drag 
with  them  into  the  lower  parts  of  the  abdomen  this  portion  of 
the  stomach,  which  is  by  nature  less  firmly  attached.  The 
passage  into  the  pylorus  becomes  more  and  more  abrupt,  and 
the  normal  discharge  of  the  contents  more  difficult.  At 
length,  the  greater  curvature  sinks  to  the  top  of  the  symphysis, 
and  the  steady  development  of  gaseous  products  of  fermenta- 
tion brings  about,  besides  an  abnormally  distended  abdomen, 
a  complete  stand-still  in  the  regular  reception  of  food,  and  a 
dangerous  general  decline  in  the  processes  of  nutrition. 

When  we  look  back  upon  the  close  and  logical  sequence  of 
these  symptoms,  and  perceive  how,  at  times,  a  disturbance,  of 
itself  trifling,  leads  to  serious  results,  we  cannot  fail  to  admire 
the  wise  provision  of  nature  by  which  the  contents  of  the 
stomach  are  thrown  off  and  the  ascension  of  the  scala  vitiosa 
prevented. 

Vomiting  is  caused  by  a  reflex  contraction  of  the  abdominal 
walls,  accompanied  by  a  simultaneous  relaxation  of  the  circular 
muscular  fibres  of  the  stomach,  together  with  a  perceptible 
shortening  of  the  oesophagus.  The  latter  involves  also  the 
cesophageal  end  of  the  stomach,  for  it  must  be  remembered 
that  the  longitudinal  muscular  fibres  of  the  oesophagus  do 
not  terminate  at  the  oasophageal  opening,  but  extend  some 
distance  upon  the  surface  of  the  stomach.  The  angle  at  which 
the  oesophagus  originates  in  the  stomach  is  also  the  starting 
point  of  longitudinal  muscular  fibres,  which  radiate  here  in 
a  stellate  manner  and  soon  are  lost.  It  cannot  be  doubted 
that  these  fibres  are  concerned  in  the  shortening  of  the  oesoph- 
agus, and  that  they,  by  virtue  of  their  origin,  strive  to  change 
the  angle  of  origin  by  several  degrees,  i.  e.,  they  open  in  a 
funnel-shaped  manner  the  cardiac  orifice,  whose  circular 
muscular  fibres  are  completely  relaxed,  and  thus  afford  the 


124  GENERAL    PATHOLOGY. 

greatest  possible  facility  for  the  discharge  of  the  contents  of 
the  stomach. 

The  act  of  vomiting,  as  before  observed,  is  a  beneficial  in- 
terruption in  the  scala  vitiosa  of  the  disturbed  digestive  pro- 
cess, although,  as  is  easily  seen,  it  only  assists  indirectly  in 
supplying  the  blood  with  nutritive  material,  by  cleansing  the 
resorptiou  territory. 

The  act  of  resorption  is  as  often  abnormally  disturbed  be- 
yond the  pylorus  as  in  the  stomach.  For  not  only  is  the 
preparation  of  carbo-hydrates,  albumen  and  fat,  which  depend 
upon  a  sufficient  secretion  of  intestinal  and  gastric  juices  and 
bile,  interfered  with,  but  especially  is  the  reception  of  the 
dissolved  nutritive  material  into  the  blood  and  chyle  easily 
disturbed.  Here,  as  in  the  stomach,  the  real  cause  is  found 
to  be  the  superficial  position  of  the  mucous  capillaries, 
which,  in  turn,  is  demanded  by  the  participation  of  the  blood 
vessels  in  the  work  of  resorption.  It  is  clear  that  as  the  blood 
vessels,  especially  those  of  the  venous  apparatus,  approach 
nearer  to  the  surface,  they  become  more  and  more  subject 
to  the  various  injurious  influences  there  present ;  and  if 
we  are  correct  in  locating  the  salient  point  of  inflammation, 
as  an  alteration  of  the  vascular  wall,  we  must  be  prepared 
to  find  upon  the  exposed  surface  of  the  mucous  membranes 
all  possible  forms  and  degrees  of  inflammatory  hypersemias 
and  exudates.  We  are  not  mistaken  in  this  expectation. 
Pathological  anatomy  chronicles  here  a  long  list  of  simple 
and  specific  inflammations,  catarrhal,  croupous  and  diph- 
theritic, tumors  and  abscesses,  all  of  which  are  found  in 
the  mucous  membranes.  In  every  decided  inflammation,  the 
capillaries,  as  a  matter  of  course,  cease  to  absorb,  and  the 
diametrically  opposed  process,  that  of  inflammatory  exudation, 
sets  in. 

Great  caution  must,  however,  be  used  in  determining  any 
form  of  enteritis.  No  organ  of  the  body  is  as  subject  to  the 
action  of  functional  hypersemia  as  the  mucous  coat  of  the 
digestive  tract,  therefore  we  must  not  ignore  the  fact  that 
the  irritation  of  the  ingesta  brings  on  functional  hyper- 
semia, and  with  it  an  increased  peristaltic  action.  The  latter, 
besides  promoting  resorption  by  pressure  upon  the  intestinal 
contents,  causes:  (1)  an  accelerated  movement  of  the  contents 
downwards  ;  (2)  a  more  abundant  secretion  of  intestinal  juice 
from  Lieberkii hn's  follicles.  As  the  intestinal  irritation  and 


DISTURBANCES   IN    THE    FORMATION   OF   BLOOD.          125 

its  accompanying  hypersemia  become  more  and  more  intensi- 
fied, the  process  of  resorption  is  subordinated  to  an  increased 
secretion  of  intestinal  juice,  and  rapid  descent  of  fecal  matter. 
We  have  now  a  condition  which  oversteps  the  limits  of  func- 
tional hypersemia  in  an  inflammatory  direction,  but  is  yet,  by 
no  means,  an  inflammation  in  effect.  Its  pathognomonic 
symptom  is  diarrhoea. 

The  phenomenon  of  diarrhoea  is,  in  some  respects,  similar 
to  that  of  vomiting ;  more  especially  in  regard  to  its  result, 
viz.,  relieving  the  stomach  of  injurious  ingesta.  Both,  there- 
fore, furnish  a  valuable  hint  for  the  physician,  who  should 
not  hesitate  to  employ  emetics  and  cathartics,  whenever  there 
is  danger  that  the  intestinal  contents  might,  by  their  continued 
presence,  act  perniciously  upon  the  intestinal  wall  and  general 
organism.  In  the  bowels,  as  well  as  in  the  stomach,  an  unusual 
detention  of  the  contents  threatens  danger  to  the  organism. 
Constipation  is  always  accompanied  by  slight  processes  offer- 
mentation  and  decomposition.  These  are  attributable:  (1)  to 
the  numberless  fermentation  and  decomposition  fungi,  whose 
presence  in  the  faeces  is  easily  demonstrated ;  (2)  to  the  final 
exhaustion  of  the  protective  action  of  the  gastric  juice  and 
bile,  against  fermentation  and  ordinary  putrefaction  furnished 
by  their  admixture  with  the  intestinal  contents. 

The  formation  of  gas  (flatulency),  due  to  hydrogen  gas  and 
its  combinations,  is  an  almost  invariable  accompaniment  of 
such  decomposition ;  then  follows  pain,  and  soon  there  can  be 
no  doubt  but  that  an  inflammation  of  the  intestinal  wall  has 
set  in.  It  is  at  first  of  a  catarrhal  character,  and  it  is  at  this 
stage  that  the  disease  should,  if  possible,  be  checked,  either 
by  natural  means  or  by  artificially  removing  the  contents  of 
the  intestines.  In  default  of  this  we  may  expect  to  see  this 
inflammatory  process  advance,  penetrate  the  layers  of  the  in- 
testinal wall,  and  reach,  finally,  the  peritoneum  (perityphlitis, 
stercoraceous  peritonitis).  The  muscular  coat  now  becomes 
inflamed,  cedematous  and  completely  paralyzed;  the  intestine 
is  distended  to  its  utmost  by  the  accumulation  of  gas  (meteor- 
ism)  ;  the  abdomen  is  greatly  swollen,  the  diaphragm  is  raised 
and  ceases  entirely  or  in  part  to  exert  its  influence  upon 
respiration.  The  crisal  symptom  of  this  disorder  is  ster- 
coraceous vomiting  which  is  apt  to  appear  when  the 
intestinal  canal  becomes  permanently  obstructed  by  intus- 
susception, cancerous  or  cicatricial  growths,  strangulated 


126  GENERAL    PATHOLOGY. 

hernia,  etc.  By  it  we  understand  a  discharge  of  the 
entire  intestinal  contents  by  the  mouth,  which  occurs  when 
the  distended  intestines  have  lost  their  power  of  contraction, 
and  no  longer  oppose  abdominal  pressure,  which  causes  the 
contents  of  the  bowels  to  be  expelled  by  vomiting. 

The  fatal  termination  is  hastened  by  the  appearance  of 
fulminating  purulent  peritonitis,  which  sets  in  as  soon  as  the 
contents  penetrate  the  intestinal  wall  and  spread  themselves 
over  the  peritoneal  surface. 

In  proportion  as  the  hypersemia  of  the  mucous  capillaries 
assumes,  instead  of  a  temporary,  a  more  permanent  character, 
the  blood  vessels  cease  to  absorb  the  nutritive  material,  as  far 
as  normal  digestion  and  blood  formation  is  concerned.  For 
this  reason  absorption  is  greatly  impaired  in  diseases  of  the 
heart  and  lungs,  when  there  is  a  permanent  hypenemia  of  the 
mucous  membrane  of  the  digestive  tract.  The  absorption  of 
chyle  is  also  somewhat  disturbed,  as  the  flow  of  chyle  de- 
pends upon  the  precision  and  regularity  of  a  number  of  fac- 
tors, such  as  an  intact  epithelium,  a  regular  contraction 
and  erection  of  the  intestinal  villi,  an  undisturbed  and  power- 
ful peristalsis,  and  an  exact  and  well-timed  filling  of  the  blood 
vessels.  It  is  clear  that  every  serious  inflammation  must 
interfere  with  the  action  of  one  or  more  of  these  factors. 
A  normal  condition  of  the  mesenteric  glands  is  also  necessary 
to  the  further  progress  of  the  absorbed  chyle.  An  inflamma- 
tory, cancerous,  or  tuberculous  intumescence  of  these  glands 
imperils  the  process  of  absorption,  just  in  proportion  as  the 
intra-glandular  lymphatics  are  more  or  less  effectively  ob- 
structed. 

Marasmus,  Defective  Nutrition. 

The  evil  effects  of  any  serious  disturbance  of  nutrition  in 
the  digestive  tract  are  apparent  to  all:  hollow  eyes,  thin  and 
emaciated  limbs,  pallid  and  withered  skin, — such  are  the 
sequelae  of  this  condition.  Marasmus  or  the  result  of  a 
prolonged  loss  of  food,  has  already  been  sketched,  where 
especial  stress  was  laid  upon  the  diminished  quantity  of  blood 
and  the  loss  of  flesh. 

Physiology  teaches  us  how  the  hungry  body,  robbed  of  its 
food,  subsists  at  the  expense  of  the  muscles  and  fat,  until, 
after  the  lapse  of  two  weeks,  it  can  no  longer,  by  preying 
upon  itself,  avert  the  deadly  suspension  of  sensibility,  and  thus 
perishes,  of  complete  exhaustion. 


DISTURBANCES   IN   THE    FORMATION   OF    BLOOD.         127 
DISTURBANCES   IN    BLOOD   CORPUSCLE   FORMATION. 

The  most  important  constituents  of  the  blood  are  the  red 
blood  corpuscles.  They  alone  possess  the  power  to  take  up 
oxygen  in  the  lungs,  and  conduct  it  in  loose  chemical  combina- 
tion to  the  tissues  of  the  body.  This  power  of  the  red  blood  cor- 
puscles is  due  to  hsemoglobin,  a  peculiar  reddish-yellow  sub- 
stance which  they  contain.  Haemoglobin  is  readily  resolved, 
by  the  action  of  alkalies  and  acids,  into  an  albuminous  body, 
globulin,  and  into  the  coloring  matter  of  the  blood,  in  its 
restricted  sense,  hsematin.  This  separation  is  more  rapidly 
accomplished  by  ozone,  especially  with  high  temperature. 
When  we  picture  to  ourselves  the  unceasing  action  of  the  in- 
spired particles  of  oxygen  upon  the  red  blood  corpuscles,  we 
can  comprehend  the  rapid  changes  which  the  molecules  of 
hsemogiobin  undergo  in  the  body,  changes  whose  magnitude 
may  be  estimated  by  a  comparison  with  the  quantity  of  pigment 
secreted  by  the  bile.  No  one  now  questions  that  bilirubin  is 
identical  with  transformed  hsematin,  but  nothing  is  known  of 
what  becomes  of  the  globulin.  At  any  rate  the  disintegration 
of  the  hsemoglobulin  calls  for  a  rapid  restoration  of  the  blood, 
and  just  here  our  knowledge  of  the  formation  of  blood  is  com- 
pletely at  fault.  We  do  not  know  to  what  degree  the  haemo- 
globin-changes are  identical  with  those  of  the  red  blood 
corpuscles,  nor  whether  the  blood  corpuscle  yields  up  its 
hsemogiobin  individually ;  whether  there  is  a  shedding  of 
hseraoglobin,  or  whether  for  each  amount  of  bilirubin  secreted 
in  the  bile  a  corresponding  number  of  red  blood  corpuscles  are 
withdrawn  from  the  circulation. 

Nature  displays  a  certain  extravagance  with  red  blood 
corpuscles,  and  slight  losses  of  blood  seem  easily  repaired. 
Still  we  meet  here  with  individual  differences,  and  the  forma- 
tion of  the  red  blood  corpuscles  is,  and  will  doubtless  remain, 
one  of  the  most  difficult  problems  of  our  science.  Little  is 
known  of  the  remote  conditions  or  the  locality  and  the 
histological  process  concerned  in  the  origin  of  the  red  blood 
corpuscles. 

In  the  red  marrow  of  the  bones  and  in  the  splenic  pulp 
of  the  mammalia,  we  find  nucleated  red  blood  corpuscles, 
which  resemble  exactly  embryonic  corpuscles  (hsematoblasts). 
Processes  of  nuclear  and  cell  division  may  be  easily  observed 
in  these  cells.  I  also  believe  I  have  demonstrated  that  these 
cells,  by  expulsion  of  their  nuclei  and  mechanical  remodeling 


128  GENERAL   PATHOLOGY. 

of  their  shape,  are  converted  into  the  well  known  bi-concave, 
non-nucleated  discs. 

According  to  the  above,  the  production  of  the  red  blood 
corpuscles  would  be  the  function  of  the  splenic  pulp  and  the 
red  marrow  of  bones,  and  disturbances  in  the  formation  of  red 
blood  corpuscles  would  be  referable  to  disturbances  in  the 
above  sources — a  hypothesis  which  entirely  agrees  with  ob- 
served pathological  facts.  So  we  shall  for  the  present  consider 
essential  ansemias  as  disturbances  of  splenic  or  medullary 
hsematosis,  without  attempting  an  exact  definition  of  the 
process  or  dwelling  upon  the  post-mortem  studies  relating 
thereto. 

Essential  Ancemias. 

An  essential  anaemia  is  a  decided  and  prolonged  pro- 
portional diminution  in  the  number  of  red  blood  corpuscles 
in  the  blood,  which  is  not  produced  by  loss  of  blood  and 
nutritive  fluids,  like  cachexia,  nor  by  the  destruction  of  the  red 
blood  corpuscles  by  means  of  poison.  One  of  two  things 
-operates  to  produce  an  essential  anaemia,  viz.,  an  insufficient 
formation  and  supply  of  red  blood  corpuscles  on  the  part  of 
the  hsematoblastic  tissues,  or  a  premature  disintegration  and 
destruction  of  the  formed  or  partially  formed  cells. 

Thus  essential  ansemias  fall  into  two  classes.  The  type 
of  the  first  class  is  the  so-called  pernicious  or  progressive 
anaemia.  In  a  few  months  this  disease,  in  the  face  of  all 
known  remedies,  reduces  the  blood,  especially  its  haemoglobin 
constituents,  to  i  or  rV  of  its  normal  quantity.  The  nutrition 
of  all  the  tissues  is  thereby  impaired ;  the  cardiac  parenchyma 
undergoes  fatty  degeneration  and  death  is  caused  by  paralysis 
of  the  heart.  In  dissecting,  we  are  astonished  at  the  para- 
doxical condition  of  the  bone  marrow.  Everywhere,  even 
replacing  the  fat  marrow  of  the  long  bones — -the  femur,  tibia 
and  humerus — we  find  an  intensely  red  marrow  containing 
numberless  nucleated  red  blood  corpuscles;  in  other  words, 
an  advanced  state  of  development  of  those  cells  in  which  the 
blood  is  deficient.  What  is  the  meaning  of  this  ?  Why  was 
the  formation  of  red  blood  corpuscles  arrested  just  before 
completion  ?  And  why  did  they  not  enter  into  the  blood  ? 
Pernicious  anaemia  is  of  rare  occurrence.  It  is  only  found 
among  the  badly  nourished  of  the  poorer  classes  of  society. 

An  anaemia  called  chlorosis,  which  is  generally  of  a  temporary 


DISTURBANCES   IN   THE   FORMATION   OP   BLOOD.         129 

character,  prevails  frequently  in  young  women  of  all  classes. 
Here,  too,  we  can  trace  a  loss  of  one-half  or  more  in  the  coloring 
matter,  i.  e.,  of  the  haemoglobin.  The  complexion  becomes 
very  pale  greenish,  and  many  disagreeable  symptoms  make 
their  appearance  (dyspepsia,  anomalous  menstruation).  The 
spleen  and  bone  marrow  require  some  assistance  in  their  func- 
tion of  blood  making,  and  this,  fortunately,  we  possess  in  iron, 
which,  if  properly  prescribed,  restores  the  normal  condition 
with  comparative  rapidity. 

In  some  of  the  other  forms  of  essential  anaemia,  the  lack  of 
red  blood  corpuscles  is  to  a  certain  extent  overlooked  in  view 
of  the  highly  singular  attitude  of  the  colorless  blood  cor- 
puscles. Pseudo-leucsemic  ansemia,  which  often  terminates 
fatally,  shows  a  diminution  in  the  quantity  of  the  blood, 
accompanied  by  an  immense  accumulation  of  colorless  blood 
corpuscles  in  the  lymphatic  glands.  These  corpuscles  cluster 
together  and  form  large-sized  tumors.  Splenic  ansemia  is 
coupled  in  the  same  manner  with  an  astonishing  increase  in 
size  of  the  spleen  and  decidedly  leucocythotic  in  character. 

An  advocate  of  the  view  that  the  hsematoblasts  arise,  not 
only  from  cell  multiplication,  but  also  from  white  blood  cor- 
puscles, would  infer  from  these  combinations  that  the  swollen 
organs  were  depriving  the  blood  of  the  constructive  material 
residing  in  the  red  blood  corpuscles.  In  a  case  of  splenic 
anaemia  in  which  I  made  a  post-mortem  examination  for 
Griesinger,  it  appeared  to  me  as  though  all  the  blood  of  the 
body  were  retained  in  the  spleen ;  the  spleen  weighed  over 
twelve  pounds,  and  the  blood  vessels  were  entirely  empty. 

The  most  enigmatical  conditions  are  found  in  leucsemic 
ansemia,  or  leucaemia.  The  loss  of  red  blood  corpuscles  is 
concealed  by  the  simultaneous  gain  in  colorless  blood  corpus- 
cles. In  blood  extracted  from  the  finger  of  the  patient,  we 
can  count  one  white  to  every  twenty,  ten,  or  even  two  red 
blood  corpuscles.  The  blood  is  of  a  raspberry  color,  and 
seen  in  bulk,  appears  streaked  with  white.  The  white  blood 
corpuscles  are  of  considerable  size,  and  not  rarely  multinuclear. 
Their  preponderance  in  the  blood  leads,  in  many  places,  to 
extensive  migrations,  occurring  either  diffused  or  in  masses. 
These  migrations  are  as  much  entitled  to  the  name  of  extrava- 
sations as  exudates,  or  even  new  formations  of  lymphatic 
parenchyma,  for  they  are  often  accompanied  by  exhausting 
hemorrhage  of  the  mucous  membrane  of  the  nose  and  intes- 


130  GENERAL    PATHOLOGY. 

tines,  and  by  a  constant  and  excessive  enlargement  of  the 
spleen,  i.  e.,  of  the  lymph  glands  (leucaemia  lienalis  or  lymph- 
atica). 

In  studying  the  formation  of  red  blood  corpuscles  I  have 
arrived  at  a  theory  of  my  own  concerning  leucaemia.  I  am 
of  the  opinion  that  the  hsematoblasts,  instead  of  becoming  red 
blood  corpuscles,  are  converted  into  certain  large,  colorless 
cell-elements  of  the  marrow.  The  latter  appear  in  moderate 
quantities  in  normal  blood  marrow,  and  are  found  in  leucaemia 
in  enormous  quantities,  not  only  in  the  bone  marrow  but,  as 
before  noticed,  in  the  blood  as  well. 

The  second  class  of  essential  anaemias  result  from  a  prema- 
ture destruction  of  red  blood  corpuscles ;  or  rather,  I  should 
say,  appear  to  result,  for  at  this  point  our  knowledge  is  most 
defective  and  uncertain.  We  know  that  the  normal  disinte- 
gration of  the  red  blood  corpuscles  gives  rise  to  a  brown 
pigment,  the  coloring  matter  of  the  bile.  Furthermore,  we 
know  that  certain  brown  and  blackish  pigment  substances  are 
formed  from  extravasated  blood,  that  the  same  or  similar 
substances  are  found  normally  in  the  spleen  and  marrow, 
and  also  in  great  abundance  in  the  spleen  of  the  frog,  where 
it  has  been  formed  from  the  disintegration  of  red  blood 
corpuscles.  We  are  thus  led  to  consider  a  rapid  destruction 
of  the  red  blood  corpuscles  as  the  cause  of  such  essential 
anaemias  as  are  accompanied  by  a  conspicuous  formation  and 
deposition  of  pigment.  Although  the  spleen  and  the  marrow  of 
bone  preside  over  the  formation  of  the  red  blood  corpuscles, 
they  are  also  the  chief  seats  of  the  pathological  disintegration 
of  the  red  blood  corpuscles,  and,  in  consequence,  also  of  the 
formation  of  pigment.  To  say  that  the  haematoplastic  sub- 
stance is  at  the  same  time  the  birthplace  and  the  deathbed  of 
the  red  blood  corpuscles  appears  like  a  surprising  assertion. 
But  this  assertion,  made  thirty  years  ago  in  the  manuals  of 
histology,  has  ever  since  maintained  its  ground,  being  sup- 
ported and  confirmed  by  recent  pathological  researches. 

The  best  known  anaemia  is  probably  melancemia  or,  more 
correctly,  anaemia  melancemica.  Severe  and  protracted  inter- 
mittent fevers  are  often  followed  by  intense  anaemia,  and  the 
spleen  is  frequently  excessively  pigmented  or  even  entirely, 
black.  The  pigment  consists  of  dark  brown  and  black  granules, 
strongly  impregnated  with  iron  and  of  irregular-shaped  flakes, 


DISTURBANCES   IN   THE   FORMATION   OF   BLOOD.         131 

lying  loosely  in  the  splenic  pulp.  Certain  particles  of  this 
pigment  are,  little  by  little,  washed  away  by  the  blood  current 
and  deposited  in  the  liver,  brain  and  kidneys,  where  they  give 
rise  to  considerable  disturbance  of  function,  especially  in  the 
brain.  If  there  be  a  renewed  attack  of  fever,  causing  a  tem- 
porarily-increased hypersemia  of  the  spleen,  we  shall  also  find, 
during  the  attack,  more  pigment  in  the  blood  of  the  melan- 
semic  patient.  Little  definite  information  can  be  had  as  to 
the  condition  of  the  marrow  in  this  unusual  disease.  Were  I  to 
assert  that  there  is  in  melansemia  a  premature  disintegration  of 
red  blood  corpuscles  in  the  spleen,  and  that  this  is  the  cause  of 
the  grave  anaemia  which  terminates  the  life  of  the  patient,  I 
should  certainly  assert  more  than  I  am  able  to  prove.  Not- 
withstanding this,  there  are,  at  least  in  melanaemia,  more  data 
from  which  to  draw  conclusions  than  in  the  succeeding  groups 
of  symptoms  which  we  now  approach. 

Melanosis,  so  called,  presents  an  inevitable  and  rapid  decline 
of  vitality,  in  conjunction  with  a  proportional  formation  and 
accumulation  of  a  brown,  or  deep,  sepia-colored  pigment. 
This  is  distributed  partly  in  solution  in  the  blood,  in  which 
case  it  is  found  in  the  urine,  which,  upon  exposure  to  the  air, 
acquires  a  dark  gray  to  a  black  color,  and  partly  as  granular 
deposits,  occurring  at  different  parts  of  the  body. 

In  the  summer  of  1881  a  case  of  melanosis  came  under  my 
notice,  in  the  Julius  hospital  of  Wiirzburg,  in  which  all  the 
bone  marrow,  which  is  normally  red,  i.  e.>  the  marrow  of  the 
vertebrae,  ribs,  sternum,  etc.,  instead  of  being  red,  was  black. 
The  same  was  true  of  the  spleen.  The  liver  also  showed 
diffused  pigmentation,  which,  under  the  microscope,  was  seen 
to  have  attacked  all  the  vascular  and  many  of  the  investing 
cells,  both  of  which  contained  brownish-black  flakes  of  pig- 
ment. 

The  resemblance  which  is  thus  far  traceable  between  mel- 
anosis and  melansemia  ends  here  ;  the  quantity  of  the  pigment 
alone  brings  about  a  radical  difference.  Melansernia-pigment 
is  a  body  rich  in  iron,  which,  combined  with  muriatic  acid  and 
ferrocyanide  of  potash,  yields  a  beautiful  Prussian  blue.  Mela- 
notic  pigment,  on  the  other  hand,  belongs  to  those  pigments 
as  yet  chemically  undetermined,  which  are  formed  normally 
in  the  choroid  coat  of  the  eye  and  the  rete  mucosum  of  the 
skin.  If,  therefore,  in  the  above-described  case  of  melanosis, 
we  are  to  consider  the  bone  marrow  and  spleen  as  the  breeding 


132  GENERAL    PATHOLOGY. 

place  of  pigment  (just  as  in  melansemia),  they  have,  un- 
doubtedly, assumed  a  function  usually  accorded  only  to  the 
choroid  coat  of  the  eye  and  the  rete  mucosum  of  the  skin. 

Another  consideration  is  the  fact 'that  melanosis  is,  in  the 
greater  number  of  cases,  associated  with  melanotic  sarcoma, 
hence  it  is  difficult  to  disprove  the  assumption  that  melanotic 
dyscrasia  is  the  result  of  a  pigment  tumor  of  the  eye  and  skin. 
This,  however,  has  always  been  a  disputed  point.  Virchow, 
otherwise  so  decided  as  to  the  primarily  local  nature  of  tumors, 
is  forced,  in  melanosis,  to  accept  at  least  the  possibility  of 
tumor-formation  preceded  by  dyscrasia.  He  calls  attention  to 
the  fact  that  melanosis  generally  attacks  those  persons  who  are 
by  nature  inclined  to  an  abnormal  formation  and  deposition 
of  pigment.  Also,  that  gray  or  white  (albino)  horses  are  es- 
pecially and  even  constitutionally  subject  to  melanosis,  so  that 
it  would  almost  appear  as  if  the  missing  pigment  of  the  eye 
and  skin  were  vicariously  secreted  in  these  black  tumors.  In 
the  case  I  have  spoken  of  as  coming  under  my  observation,  I 
found,  both  in  the  liver  and  spleen,  a  soft,  spherical,  black 
tumor  of  the  size  of  a  walnut,  a  section  of  which  showed  a 
puffy,  protruding  surface.  Each  nodus  was  imbedded  to  such 
an  extent  in  the  diffusely  blackened  parenchyma,  respect- 
ively of  the  liver  and  spleen,  that  they  could  only  have  been 
secondary  formations. 

In  the  liver  are  scattered  throughout  the  entire  organ 
numerous  points,  marking  the  starting  place  of  microscopi- 
cally minute  nodes,  growing  out  of  the  proliferated  endo- 
thelia  of  the  blood  vessels.  The  latter  were  everywhere  of  a 
brown  or  black  color,  in  all  gradations  of  shades,  from  a 
light,  diffused  brown,  to  a  paranuclear  deposit  of  deep  black 
granules  and  flakes.  From  such  a  soil  the  tumor  had  formed. 

There  is,  furthermore,  a  melanotic  dyscrasia,  i.  e.,  the  blood, 
having  an  abnormal  constituency  of  diffusible  coloring  matter, 
gives  it  up  to  the  endothelia  of  the  capillaries,  which  condense 
it  into  black  pigment  granules.  When  a  certain  stage  is 
reached  in  this  disposition,  the  endothelium  in  question  begins 
to  divide  and  form  sarcomatous  tumors.  It  is  possible  that 
the  coloring  matter  reaches  the  blood  by  means  of  the  pre- 
mature disintegration  of  the  red  blood  corpuscles,  and  that 
the  decay  really  takes  place  in  the  spleen  and  bone  marrow, 
but  this  is,  as  yet,  mere  supposition. 

Finally  we  must  note,  at  this  point,  a  very  singular  group 


DISTURBANCES   IN   BLOOD  PURIFICATION.  133 

of  symptoms,  characterized  by  local,  dark  gray  discoloration  of 
the  skin,  and  anaemic  debility,  with  which  is  often  associated  a 
degenerated  condition  of  the  renal  capsules.  This  disease,  first 
described  by  Addison,  has  received  the  name  of  Addison's 
Disease. 

IV.  DISTURBANCES  IN  BLOOD-PURIFICATION. 

The  purification  of  the  blood,  which  is,  strictly  speaking, 
the  removal  from  it  of  the  retrograde  products  of  metamor- 
phosis, is,  as  we  know,  entrusted  mainly  to  the  three  chief 
organs  of  the  body,  i.  e.,  lungs,  kidneys  and  liver.  Each  of 
these  organs  may  be  hindered  in  the  exercise  of  its  especial 
function  by  all  sorts  of  pathologico-anatomical  changes,  and  ex- 
cretory products,  may,  in  consequence,  accumulate  in  the  blood. 
Thus,  we  find  an  accumulation  of  carbonic  acid,  urea,  and 
biliary  products  in  the  blood,  and  may,  with  propriety, 
regard  these  accumulations  as  the  leading  phenomena  of  the 
groups  of  symptoms  due  to  derangements  of  these  organs 
respectively. 

The  functional  disturbances  of  the  excretory  organs,  how- 
ever, rarely  present  themselves  in  so  simple  a  form.  For  the 
lung  is  not  alone  intended  to  throw  off  carbonic  acid,  but  for 
the  reception  of  oxygen  as  well.  Therefore,  we  find  in  the 
symptomatic  picture  of  the  disturbances  of  respiration,  that 
the  lack  of  oxygen  plays  at  least  as  important  a  role  as  the 
poisoning  from  carbonic  acid.  The  most  important  of  the 
affections  of  the  kidney  is  nephritis.  Nephritis  not  only 
threatens  the  destruction  of  the  epithelium  that  secretes  urine, 
and  thereby  the  organism  with  uraemia,  but  almost  invariably 
produces  changes  in  the  capillaries  of  the  Malpighian  tufts, 
in  consequence  of  which  the  albumen  of  the  blood  passes  into 
the  urine,  and  albuminuria  becomes  a  prominent  symptom. 
There  is  still  much  doubt  as  to  what  substances  the  liver 
extracts  from  the  blood,  in  order  to  form  bile ;  but  as  we  find 
decomposed  hsematin  thrown  off  with  the  bile,  we  are  thus 
inclined  to  look  upon  the  remaining  constituents  of  the  bile 
as  products  of  the  disintegration  of  the  red  blood  cor- 
puscles. Chlolsemia  does  not  signify,  by  any  means,  a 
retention  of  the  formative  material  of  the  bile,  in  the  sense 
of  a  retention  of  carbonic  acid  and  urea,  but  only  a  resorp- 
tion  dyscrasia,  brought  about  by  the  reabsorption  of  the  bile 
from  the  biliary  ducts.  If  we  are  correct  in  defining  hsema- 


134  GENERAL    PATHOLOGY. 

togenous  jaundice  as  caused  by  blood  pigment  which  has  dis- 
integrated in  the  blood  (independently  of  the  liver),  it  must 
be  regarded  as  an  exception  to  the  above.  It  is  not  impossible 
that  similar  discoveries  yet  remain  to  be  made  as  regards  the 
other  elements  concerned  in  the  production  of  bile,  although 
the  function  of  the  liver  cells  does  not  appear  to  be  readily 
disturbed.  It  is  most  astonishing  how  protoplasm  will  still 
continue  to  secrete,  even  when  almost  obliterated  by  an  im- 
mense fat  drop,  and  how  an  amyloid  liver,  not  possessing  a 
single  normal  liver  cell,  will  continue  to  furnish  the  requisite 
quantity  of  bile.  But  the  facts  speak  for  themselves.  It  is 
only  when,  by  some  few  anatomical  changes  (such  as  gall- 
stones, catarrh  of  the  efferent  ducts,  etc.),  the  discharge  of  bile 
is  hindered,  that  the  bile  passes  into  the  blood,  and  a  charac- 
teristic dyscrasia  is  produced. 

Alongside  of  this  incongruity  between  a  defective  purifi- 
cation of  the  blood  and  a  general  disturbance  of  function 
in  an  organ  intended  for  the  purification  of  the  blood,  another 
circumstance  forces  us  to  increase  the  number  of  typical 
groups  of  symptoms  associated  with  the  organs  concerned  in 
the  purification  of  the  blood.  For  it  sometimes  occurs  that 
there  is  an  accumulation  of  excretory  matter  in  the  blood,  far 
exceeding  the  capacity  of  the  organ  designed  for  its  removal, 
and  this  without  any  apparent  pathological  change  in  the 
latter.  This  condition,  however,  only  arises  (1)  when  there 
is  produced  an  abnormally  large  quantity  of  the  substance  in 
question ;  (2)  when  it  is  a  chemically  slightly  diffusible  body, 
which  appears  normally  in  small  quantities,  and  which  the 
glands  are,  therefore,  unable  to  secrete  in  large  amounts.  Of 
such  substances  uric  acid  and  glucose  are  the  most  important. 
The  retention  of  these  in  the  blood  produces  uric  acid-  and 
sugar-dyscrasias,  which  will  be  considered  more  at  length 
under  the  head  of  the  non-excretory  dyscrasias. 

DISTURBANCES  OF    RESPIRATION. 

There  is  perhaps  no  organ  in  the  body  which  undergoes 
so  many  and  so  varied  pathological  changes  as  the  lung. 

Almost  all  of  these  changes  are  detrimental  to  absorption, 
to  a  greater  or  less  degree.  Inflammatory  exudates  fill  the 
alveoli  and  prevent  the  atmospheric  air  from  coming  in 
contact  with  the  blood  of  the  pulmonary  capillaries,  cellular 
infiltration  of  the  connective  tissue  of  the  lungs  compresses 


DISTURBANCES   IN   BLOOD-PURIFICATION.  135 

the  pulmonary  capillaries  and  hinders  the  blood  from  coming 
in  contact  with  the  air  in  the  alveoli.  A  similar  effect  is  pro- 
duced by  hemorrhagic  and  liquid  transudations,  which  flood 
the  organ  of  respiration  over  a  more  or  less  extended  space ; 
and  also  by  the  emphysematous  atrophy  of  the  alveolar  septa, 
and  the  compression  of  the  lungs  in  the  pleural  cavity  by 
means  of  inflammatory  or  non-inflammatory  effusions.  But 
whatever  the  original  cause  may  be,  we  must  always  remember 
that  a  defective  supply  of  air  and  a  defective  supply  of  blood 
to  the  lungs  lessens  or  prevents  that  contact  of  air  and  blood 
which  is  necessary  to  perfect  interchange  of  gases.  We  must, 
therefore,  include  under  difficulties  of  respiration,  not  alone 
those  diseases  which  are  peculiar  to  the  lungs,  but  everything 
which  acts  injuriously  upon  the  air  and  blood  paths,  either  in 
the  main  trunks  or  in  their  ramifications.  Foreign  bodies,  com- 
pression of  the  trachea,  spasm  or  oedema  of  the  glottis,  pseudo- 
membranous  (croupous)  accumulations  in  the  larynx  and 
trachea,  catarrhal  secretions, — all  have  their  effect  upon  the 
respiratory  process.  So  also  have  various  defects  in  the  valves 
of  the  heart,  and  embolism  of  the  pulmonary  artery  and  its 
branches.  Even  an  imperfect  composition  of  the  blood  affects 
respiration.  A  deficiency  of  red  blood  corpuscles  indicates  a 
proportional  loss  of  haemoglobin.  Too  few  red  corpuscles 
represent  a  proportionate  deficiency  in  the  gas-exchanging 
haemoglobin,  and  when  in  cholera  the  watery  secretions  of  the 
mucous  membranes  of  the  digestive  tract  has  produced  the 
dreaded  inspissation  of  the  blood,  there  is  an  immediate 
decline  below  normal  in  the  interchange  of  gases  contained  in 
the  blood. 

There  are  many  other  causes  of  disturbed  respiration  which 
ought  to  be  enumerated,  and  this  variety  in  the  causes  con- 
trasts singularly  with  the  monotony  in  their  operation.  The 
result  is  invariably  the  same ;  on  the  one  hand,  a  lack  of 
oxygen  in  the  blood,  on  the  other,  an  excess  of  carbonic  acid. 

We  know,  from  various  experiments  performed  on  animals, 
that  a  deficiency  of  oxygen  is  felt,  first  of  all,  in  an  increased 
excitation  of  the  respiratory  centre.  A  lack  of  oxygen  is, 
therefore,  correctly  regarded  as  the  prime  instigator  of  all 
those  modifications  of  respiration  which  have  for  their  object 
a  heightened  interchange  of  gases  and  blood  in  the  lungs, 
which  are  known  under  the  generic  name  of  dyspnoea,  short- 
breath,  or  still  better,  difficulty  of  breathing. 


136  GENERAL,   PATHOLOGY. 

The  heightened  excitation  of  the  respiratory  centre  is  only 
possible  as  long  as  the  blood  contains  a  certain  proportion  of 
oxygen.  With  the  loss  of  this,  the  excitation  of  the  respira- 
tory centre  ceases,  and,  after  a  short  expiration,  breathing  is 
suspended. 

An  excess  of  carbonic  acid  in  the  blood  works  like  a  nar- 
cotic, at  first  rousing  then  rapidly  stupefying  the  entire  ner- 
vous system.  Its  effect  is,  therefore,  not  unlike  that  produced 
by  a  deficiency  of  oxygen. 

Both  agencies  appear  in  intimate  association  in  every  imagi- 
nable degree  of  intensity,  forming,  in  connection  with  their 
respective  phenomena,  an  extensive  and  characteristic  chain 
of  symptoms,  the  most  prominent  of  which  we  will  now 
proceed  to  consider. 

Disturbances  of  breathing,  in  their  slightest  forms,  are 
synonymous  with  those  general  circulatory  disturbances  de- 
scribed (p.  118)  under  the  head  of  cyanosis.  Persons  troubled 
with  emphysema,  or  affections  of  the  heart,  are  notably  disin- 
clined to  violent  bodily  exercise,  to  mounting  stairs,  walking 
rapidly,  etc.  Experience  has  taught  them  the  necessity  of  a 
quiet  deportment,  L  e.,  the  least  possible  consumption  of 
oxygen  and  the  avoidance  of  unusual  respiratory  exertions, 
the  infringement  of  which  rule  is  sure  to  bring  on  an  attack, 
even  though  slight,  of  dyspnoea. 

Dyspnoea,  or  difficult  breathing,  is,  next  to  restriction  in 
the  consumption  of  oxygen,  the  only  but  also  effective 
means  employed  by  the  organism  to  restore  normal  inter- 
change of  gases.  Difficult  respiration  implies  in  all  cases 
more  powerful  inspiration.  The  increased  power  is  derived 
from  more  than  one  source.  A  deep  breath  and  an  accelerated 
breath  lead  to  the  same  result.  As  these  conditions  cannot 
be  conveniently  combined,  they  are  employed  alternately,  the 
preference  being  given  to  one  or  to  the  other  according  to 
circumstances.  Where  a  deep  breath  is  painful,  as  in 
pleurisy,  we  find  a  rapid,  superficial  respiration.  In  general, 
however,  the  deep  breath  is,  in  spite  of  the  unavoidable 
retardation,  the  most  efficient  correction  of  a  disturbed  gaseous 
interchange  in  the  blood. 

The  altered  rhythm  of  respiration  is  aided  on  occasion, 
by  various  expedients.  Thus,  inhalation  is  expedited  by  di- 
lating the  nostrils,  and  by  stretching  the  head  and  neck.  Ac- 
cessory muscles  are  called  in  play.  In  inspiration,  the  inter- 


DISTURBANCES   IN    BLOOD-PURIFICATION.  137 

costal  muscles,  and  the  sterno-cleido-mastoids ;  in  expiration, 
the  diaphragm  and  the  depressor  muscles  of  the  shoulder, 
which,  through  the  weight  of  the  upper  extremities,  exert  a 
lateral  pressure  on  the  thorax. 

In  accordance  with  the  well-known  action  of  the  respiratory 
mechanism  upon  the  circulation,  dyspnoea  accelerates  not 
only  inspiration  and  expiration,  but  also  the  blood  changes 
in  the  lung,  so  that  it  is,  in  fact,  the  best  alleviation  for  the 
trouble.  Its  operation,  aided  by  the  will  power  of  the  patient, 
is,  in  slight  attacks,  very  thorough;  so  much  so,  that  the  aim 
is  sometimes  overshot,  and  an  excess  of  oxygen  accumulates 
in  the  blood,  a  condition  which  is,  naturally,  only  of  short 
duration.  Soon  the  ever-active  cause  of  the  disturbed  res- 
piration again  occasions  defective  blood  purification,  and 
dyspnoea  is  once  more  established.  Thus  it  is  that  dyspnoea 
is  prone  to  return  periodically,  and  in  this  phase  is  called 
asthma.  Much  effort  has  been  made  to  ascribe  the  periodicity 
of  asthmatic  attacks  to  other  causes,  viz.,  to  a  neurosis  (asthma 
nervosum),  or  as  the  result  of  a  periodical  accumulation  of 
certain  small  crystals  in  the  bronchial  secretion  (asthma  crys- 
tallinum).  When  the  impeded  respiration  steadily  grows 
worse,  and  is  not  to  be  overcome  by  dyspnoea,  there  appear, 
sooner  or  later,  the  symptoms  of  gradual  suffocation.  The 
leading  phenomenon  in  this  group  of  symptoms  is  the  impaired 
sensitiveness  of  the  respiratory  centre,  which  is  due  to  the  in- 
creasing deficiency  of  oxygen  in  the  blood.  The  breathing 
and  the  circulation  grow  weaker,  the  latter  appears  almost 
suspended,  and  asphyxia  is  the  result.  The  narcotic  properties 
of  the  over  accumulation  of  carbonic  acid  become  more  visible. 
The  patient  succumbs  to  a  general  apathy,  stupefaction  and 
somnolence,  associated  with  convulsive  twitchings  of  individual 
muscles. 

In  the  group  of  symptoms  of  gradual  suffocation  there  is 
occasionally  found  a  most  ill-omened  appearance,  viz.,  inter- 
mittent breathing,  known  as  the  Cheyne-Stokes  respiration.  In 
this  an  entire  cessation  of  breathing,  lasting  from  three  or  four 
up  to  thirty  or  forty  seconds,  will  be  followed  by  respirations 
which  rapidly  grow  deeper  and  stronger  until  a  pronounced 
dyspnoea  is  established ;  these,  in  turn,  become  suddenly  slower 
and  less  deep,  until  they  are  at  last  again  entirely  suspended. 
This  paroxysm  may  be  repeated  from  one  to  five  times  in  a 
minute.  There  is  a  diversity  of  opinion  as  to  whether  this 


138  GENERAL   PATHOLOGY. 

intermittent  irritation  of  the  respiratory  centre  arises  from  a 
lack  of  oxygen  or  an  excess  of  carbonic  acid,  but  all  are 
agreed  that  it  denotes  a  gradual  crippling  of  its  activity. 

Sudden  suffocation  is  occasioned  not  alone  by  the  hangman's 
rope,  but  equally  well  by  spasm  of  the  glottis,  by  obstruction 
in  the  trachea,  by  pressure  on  the  trachea  in  goitre,  or  even 
by  haemoptysis  in  consumptives. 

The  painful  struggles  which  in  these  cases  precede  death 
are  due  mainly  to  the  withholding  of  oxygen  from  the  blood. 
The  proportion  of  the  latter  decreases  inside  of  thirty  seconds 
from  lb%  to  2.6-1.5%.  By  this  means  all  the  centres 
situated  in  the  brain  become  violently  excited  ;  the  respiratory 
centre,  the  vascular  centre,  the  centres  that  preside  over  the 
dilatation  of  the  pupil,  the  pneumogastric  centre,  etc.  The 
unfortunate  individual  gasps  vainly  for  breath,  and  a  general 
bodily  uneasiness  is  followed  by  twitching  and  convulsions, 
which  violently  distort  and  rack  the  bodv.  At  last  respira- 
tion ceases.  The  tonic  contraction  of  all  the  small  arteries 
rapidly  raises  the  blood  pressure  to  a  temporary  height  of  160 
mm.,  the  pupils  dilate  to  their  utmost,  and  the  irritation  of 
the  pneumogastric  causes  first  a  slowing,  then  a  complete  ces- 
sation of  the  cardiac  contractions.  After  a  few  moments  death 
ensues. 

DERANGEMENTS   IN   THE   FUNCTIONS   OP   THE   KIDNEYS. 

(a)  Urcemia. 

The  office  of  the  kidney  is,  as  we  know,  to  separate  the 
superfluous  water  from  the  body  and  also  to  cast  off  all  the 
bodily  products  of  disintegration  which  are  soluble  in  water. 
From  the  surface  of  the  intestines  there  passes  throughout  the 
entire  body  to  the  surface  of  the  kidneys  a  continuous  stream 
of  water,  moving  now  rapidly,  now  slowly,  washing  out  the 
organs  of  the  body  and  uniting  the  products  of  their  disinte- 
gration to  form  urine. 

The  epithelium  which  invests  the  convoluted  uriniferous 
tubules  possesses  a  specific  attraction  for  substances  peculiar 
to  urine,  such  as  urea,  uric  acid,  etc.,  and,  in  fact,  for 
almost  all  organic  substances  which  occasionally  pollute  the 
blood.  The  latter  are  extracted  by  the  epithelia  from  the  blood 
of  the  capillary  vessels  which  invest  the  tubules,  and  are  then 
precipitated  into  the  watery  current,  which,  coming  from  the 
Malpighian  tufts,  flows  in  a  rapid  stream  through  the  urinife- 


DISTURBANCES   IN   BLOOD-PURIFICATION.  139 

rous  ducts.  The  secretion  of  the  tuft  consists,  mainly,  of 
water  and  salts.  In  quantity,  it  is  regulated  exactly  by  the 
rapidity  of  the  blood  current  through  the  Malpighian  tuft. 
The  secretion  of  the  kidney  is  consequently  increased  by  every 
active  hyperaemic  condition  of  the  organ.  The  urine  becomes, 
at  the  same  time,  abundant,  clear  and  watery.  The  relative 
amount  of  the  solid  constituents  diminishes,  but  the  absolute 
quantity  remains  uniform,  or  is,  perhaps,  slightly  increased. 
Renal  congestions  are  chiefly  traceable  to  the  presence  of 
urinary  matters  in  the  blood,  especially  in  the  renal  epithelia. 
It  cannot  yet  be  proved  whether  there  is  a  nervous  centre, 
which,  being  especially  sensitive  to  attacks  from  such  sub- 
stances, reacts  against  them  by  dilating  the  renal  arteries. 
The  appearance  of  the  so-called  watery  diabetes  (Diabetes 
Insipidus)  would  thus  be  referable  to  a  further  irritation  of 
such  a  centre. 

When  the  secretion  of  urine  is  suddenly  and  completely 
arrested,  there  results  at  once  an  accumulation  of  urea  in  the 
blood,  known  as  uraemia.  Epileptic  convulsions  are  followed 
by  profound  insensibility  (comp.  Eclampsia,  p.  86),  which,  after 
several  attacks,  often  ends  in  coma  and  death.  These  symp- 
toms can  be  produced  in  animals  by  ligating  the  two  ureters. 
An  analysis  of  the  blood  of  such  animals  shows  0.040-60 
gramme  of  urea  to  100  grammes  of  blood,  while,  in  normal 
blood,  there  is  at  most  0.016-20  gramme  of  urea.  The  in- 
crease of  urea  is  distinctly  demonstrable  in  the  muscular 
juices,  as  well  as  in  all  the  bodily  parenchymas.  This  abrupt 
and  complete  stoppage  of  the  secretion  of  urine  is  rarely 
found  in  man.  Accordingly,  the  phenomena  of  uraemia  are 
only  seen  at  long  and  disconnected  intervals,  between  which 
the  blood  poisoning  is  only  manifested  in  an  apathy  and  an  ab- 
stracted, sleepy  condition,  sometimes  joined  to  severe  headaches. 

Vomiting  and  diarrhoea,  the  frequent  concomitants  of 
uraemia,  are  generally  regarded  as  the  result  of  vicarious 
secretion  by  the  digestive  tract,  because  in  both  evacuations 
the  presence  of  urea  is  readily  shown.  It  is,  however,  a 
question  whether  these  symptoms  have  not  in  some  way 
to  do  with  the  watery  secretion  which  accompanies  that  of 
urea,  and  which  must  in  some  way  find  an  escape.  That  this 
over-accumulation  of  water  causes  certain  local  cedemas  of  the 
skin  (eyelids),  a  frequent  symptom  in  uraemic  patients,  cannot 
be  doubted,  although  the  theory  of  Traube,  which  attributes 


140  GENERAL   PATHOLOGY. 

ursemic  convulsions  to  an  oedema  of  the  brain,  has  not  yet 
been  confirmed. 

Hemorrhages  are  also  included  among  the  symptoms  of 
unemia.  They  arise  from  the  unusual  blood  pressure  in  the 
arteries  and  occur  partly  from  large-sized  vessels  whose  re- 
sistance has  been  already  weakened  by  disease,  and  partly 
from  capillaries  and  arterioles,  as  punctiform  hemorrhages. 
These  latter  are  best  observed  in  the  retina  of  the  eye.  The 
complete  but  often  only  temporary  blindness  of  those  suffer- 
ing from  uraemia  is  not  owing  to  any  local  affection  of  the  eye, 
but  to  paralysis  of  the  centres  presiding  over  vision. 

The  symptoms  of  uraemia  are  to  be  dreaded  in  proportion 
as  the  epithelia  of  the  convoluted  uriniferous  tubules  are  unable 
to  perform  their  functions.  This  is  the  case  (1)  when  the 
urine  cannot  be  discharged  from  the  tubules,  (2)  when  the 
epithelia  themselves  are  injured  and  incapable  of  their 
function,  (3)  when  the  kidneys  are  imperfectly  supplied  with 
blood.  One  or  more  of  these  conditions  are  generally  present 
in  nephritis,  and  thus  nephritis  produces,  next  to  ischuria,  due 
to  obstruction  of  the  large  urinary  passages,  the  greatest 
number  of  uraemic  symptoms.  There  exist,  however,  so  many 
varieties,  degrees,  and  stages  of  nephritis,  that  the  danger 
from  uraemia  cannot  be  accurately  foretold.  The  following 
group  of  symptoms,  which  are  apt  to  appear  in  kidney  dis- 
orders, present  quite  a  different  aspect. 

(6)  Albuminuria  and  Hydrcemia. 

A  local  dilatation  of  the  renal  blood  vessels  in  the  Mal- 
pighian  tufts  causes  a  local  increase  of  lateral  pressure,  which 
although  moderate,  suffices  for  the  continued  transudation  of 
that  quota  of  the  watery  portion  of  the  blood  which  consti- 
tutes the  water  of  the  urine.  The  quantity  of  urine  produced 
is  in  proportion  to  the  amount  of  blood  flowing  through 
the  kidneys ;  in  other  words,  the  more  the  motive  power  of 
the  arterial  blood  is  expressed  in  rapidity  rather  than  in 
lateral  pressure  and  friction,  the  greater  is  the  quantity.  This 
regulation  presupposes  a  free  and  unhindered  flow  of  blood 
through  the  renal  veins,  and  also  a  perfectly  intact  condition 
of  the  relatively  weak  vascular  wall  of  the  Malpighian  tuft. 
Many  well-established  experiments  have  shown  the  results 
produced  by  a  defective  fulfillment  of  these  two  conditions, 
which  have  been  confirmed  by  observations  at  the  bedside. 


DISTURBANCES    IN    BLOOD-PURIFICATION.  141 

By  obstructing  the  renal  vein,  we  produce  albuminuria  and 
a  decrease  of  urine,  which  continue  until  the  obstruction  is 
removed.  In  this  case,  the  retarded  blood  changes  lead  to  a 
diminished  secretion  of  water,  and  the  increase  of  lateral 
pressure,  on  the  other  hand,  to  the  filtration  through  the  walls 
of  the  Malpighian  tuft  of  one  of  the  less  diffusible  constitu- 
ents of  the  blood,  viz.,  the  sero  albumen. 

A  half-hour's  exclusion  of  the  blood,  by  ligation  of  the 
renal  artery,  will  eifect  an  alteration  in  the  nutrition,  i.  e.,  the 
chemico-physical  composition  of  the  blood  vessels  in  general, 
and  of  the  Malpighian  tufts  in  particular.  What  follows? 
The  urine  diminishes  in  quantity  and  is  found  to  contain 
albumen  ;  the  kidneys  pass  through  all  the  changes  of  genuine 
nephritis ;  the  epithelia  of  the  convoluted  uriuiferous  tubes 
undergo  fatty  degeneration  and  are  thrown  off  in  the  shape  of 
compound  granule-cells  or  fatty  detritus.  The  parenchyma 
around  the  pyramids  of  Ferrein  collapses  and  gives  the  surface 
of  the  organ  an  uneven,  granular  appearance.  There  occurs 
at  the  same  time  a  cellular  infiltration  of  the  connective 
tissue,  succeeded  by  shrinkage  and  a  permanent  condition  of 
granular  atrophy. 

The  heightened  friction  of  the  blood,  exerted  upon  the  in- 
flamed walls  of  the  Malpighian  tufts,  is  in  this  instance  re- 
sponsible for  the  retarded  circulation,  the  intensified  lateral 
pressure,  and  the  albuminous  infiltrate.  The  changes  in  the 
uriniferous  tubes  may  eventually  produce  uraemia.  Every 
secretion  of  albumen  in  the  urine  (albuminuria)  which  occurs 
in  kidney  diseases  proceeds  from  one  of  two  factors,  viz., 
venous  congestion  or  changes  in  the  vascular  walls  of  the 
Malpighian  tufts.  To  trace  how  first  one,  then  the  other  of 
these  factors  leads  to  albuminuria  and  to  the  other  typical 
groups  of  symptoms,  not  only  in  the  various  form  of  nephritis, 
but  also  in  the  congested  kidney,  in  amyloid  degeneration,  in 
partial  obstructions  of  blood  vessels,  etc.,  would  lead  us  too 
far.  Such  a  consideration  belongs  to  the  province  of  special 
pathology.  Only  with  albuminuria  proper  are  we  to  concern 
ourselves. 

The  albumen,  having  penetrated  the  walls  of  the  tortuous 
vessels,  reaches  the  investing  space  of  the  Malpighian  capsule, 
which  latter  is  the  pouch-like  commencement  of  a  uriniferous 
tubule.  If  in  animals  where  an  artificial  albuminuria  has 
been  produced,  the  kidney  be  ligated,  removed  and  boiled,  the 


142  GENERAL   PATHOLOGY. 

Malpighian  tufts  are  found  enveloped  by  a  capsule  of  coagu- 
lated albumen,  which  fills  the  investing  space. 

In  the  further  passage  of  the  albuminous  secretion  into  the 
uriniferous  tubules  it  takes  up  the  secretions  of  the  urinary 
epithelia,  and  becomes  more  and  more  acid.  In  proportion 
as  this  occurs,  the  secreted  albumen  displays  a  tendency 
towards  coagulation  which,  at  length,  develops  into  the 
"fibrinous  casts,"  of  the  uriniferous  tubules.  This  term  is 
applied  to  certain  delicate-shaped  hyaline  coagula,  which 
slowly  collect  as  a  sediment  in  the  urine,  and  are  recognized 
microscopically.  A  study  of  these  casts  convinces  us  that 
they  are  thrown  off  from  the  uriniferous  tubules,  and  that, 
while  their  ends  are  still  growing  by  apposition,  their  middle 
portions  are  loosened,  compressed,  and  rounded  off  by  the 
urine. 

The  amount  of  albumen  contained  in  the  urine  varies  from 
the  most  minute  quantity,  which,  upon  boiling,  produces  an 
almost  imperceptible  cloudiness,  up  to  2,  3  and  even  4%, 
which  yields  upon  boiling  a  cheesy  coagulate. 

Albuminuria  signifies  a  corresponding  loss  of  serum  albu- 
men on  the  part  of  the  blood,  which,  in  its  normal  condition, 
contains  8  to  9  parts  by  weight  of  the  latter  to  1  to  2 
parts  by  weight  of  salts,  fats  and  extractives,  and  90  of  water. 
The  blood  would  thus  become  more  and  more  watery,  were 
it  not  for  the  thorough  compensation  effected  by  the  additional 
supply  of  nutritive  albumen.  The  results  thus  -produced  are 
really  astonishing.  In  nephritis,  for  instance,  the  daily  loss 
of  albumen  amounts  to  five,  six,  or  seven  grammes,  or  even 
more,  although  it  is  well  known  that  patients  suffering  from 
nephritis  are  not  necessarily  poorly  nourished  nor  hydrsemic. 
With  the  exception  of  an  acute  watery  composition  of  the 
blood,  caused  by  suppression  of  urine,  hydrseraia  does  not 
appear  until  the  assimilation  of  the  nutritive  albumen  has 
been  checked  by  a  simultaneous  prostration  of  gastric  and 
intestinal  digestion.  This,  it  must  be  acknowledged,  occurs 
often  in  diseases  of  the  kidneys. 

The  thinness  of  the  hyrdsemic  blood,  although  not  the  only, 
is  the  chief  predisposing  cause  of  the  much  to  be  dreaded 
renal  dropsy.  Even  Hippocrates  comments  upon  the  foamy, 
i.  e.  albuminous,  urine  of  certain  dropsies.  We  now  know 
that  the  appearance  of  dropsy  is  secondary  to  the  albuminous 
condition  of  the  urine. 


DISTURBANCES   IN   BLOOD-PURIFICATION.  143 

If  hydrsemia  furnishes  the  most  important  predisposing 
cause,  we  find  in  the  weight  of  the  blood  the  most  im- 
portant localizing  factor  of  this  form  of  dropsy.  Appearing 
first  in  the  most  dependent  portions  of  the  body,  it  not  unfre- 
quently  changes  its  seat  according  to  the  position  of  the 
patient.  The  feet  are  favorite  seats,  although  at  first  an 
elevated  position  of  the  limbs  is  all  that  is  required  to  cause 
the  dropsy  to  disappear. 

In  addition  to  the  weight  of  the  blood,  various  other  local 
causes  might  be  mentioned,  for  example,  local  irritations  of 
the  skin.  It  has  been  asserted  that  a  particular  kind  of  en- 
dermic  medication  will  attract  water  to  the  spot  in  question 
and  thus  imitate  a  local  dropsy. 

The  later  stages  of  renal  dropsy  are  identical  with  those  of 
cardiac  dropsy  (see  p.  119). 

(c)  Glyccehcemia.    Diabetes  Mellitus. 

Normal  blood  contains  a  very  slight  amount  (ranging  in 
the  decimals  of  a  thousand)  of  grape  sugar.  The  greater  part 
of  this  sugar,  after  having  been  converted  into  lactic  acid,  be- 
comes oxidized  and  is  finally  eliminated  as  carbonic  acid  and 
water.  The  small  remaining  portion  is  excreted  by  the  kid- 
neys, and  appears  as  one  of  the  normal  constituents  of  the 
urine. 

As  much  as  a  half  per  cent,  of  sugar  is  found  in  the  blood  in 
diabetes.  Sugar  is  present  in  all  secretions  and  parenchyma 
juices,  and,  in  fact,  in  all  the  nutritive  fluids  of  the  body. 

Saccharine  matter  causes  an  increased  concentration  of  the 
blood,  and  this,  in  turn,  produces  the  same  effect  as  profuse 
perspiration  or  highly-salted  food,  viz.,  extreme  thirst,  leading 
to  excessive  drinking  and  increased  urination.  In  diabetes 
mellitus,  accordingly,  large  quantities  of  water  are  imbibed 
and  subsequently  secreted  by  the  urine.  Six  to  ten  and  twenty 
pounds  of  urine  are  sometimes  voided  daily.  This  urine  is  pale, 
slightly  cloudy  and  feebly  acid,  somewhat  foamy,  of  a  stale  odor, 
and  sweet  taste.  It  contains  from  three  per  cent,  to  ten  per 
cent,  of  sugar.  Its  specific  gravity  ranges  from  1.025  to  1.040. 
Its  viscidity  is  sometimes  one  of  the  first  indications  of  glu- 
cosuria. 

A  small  amount  of  albumen  is  frequently  found  in  connec- 
tion with  the  sugar  in  diabetic  urine.  Of  greater  importance 
is  the  invariable  increase  in  the  excretion  of  urea.  Although 


144  GENERAL  PATHOLOGY. 

the  proportion  of  urea  in  diabetic  urine  is  comparatively 
small,  we  find  that  the  amount  secreted  within  a  period  of 
twenty-four  hours  is  double  and  treble  the  normal  quantity. 

Thus  we  perceive  that  this  continuous  washing  out  deprives 
the  body  of  much  organic  matter,  which,  in  the  normal  pro- 
cess of  oxidation,  serves  as  valuable  combustive  material  or  as 
products  of  decomposition.  Assimilation  is,  undoubtedly, 
greatly  and  abnormally  increased.  In  order  to  maintain  a 
proper  equilibrium,  corresponding  nutritive  supplies  are  eaten. 
A  person  suffering  from  diabetes  will,  if  he  can  afford  it,  eat 
two  or  three  times  as  much  as  in  health.  This  additional 
supply,  although  sufficient  to  restore  the  balance  in  slight 
cases,  does  not  meet  the  demands  of  a  more  severe  attack. 
The  organs,  instead,  emaciate  and  atrophy.  Especially  striking, 
in  view  of  the  corpulency  by  which  it  is  generally  preceded, 
is  the  loss  of  fat.  The  muscles  tire  easily,  the  movements  are 
languid,  the  contractions  of  the  heart  lose  their  vigor,  and  the 
pulse  beats  feebly.  All  the  glands  are  reduced  in  size,  and 
the  genital  glands  become  sterile. 

The  disturbed  nutrition  is  apparent  in  the  skin,  in  various 
ways.  It  becomes  thin,  shriveled,  dry  and  pale,  and  the  hair 
follicles  drop  out.  It  exhibits,  also,  a  peculiar  vulnerability, 
manifested  in  a  tendency  to  all  sorts  of  inflammations,  paro- 
nychia  and  furunculus,  which  are  apt  to  be  prolonged  and  to 
terminate  in  gangrene.  The  fatal  termination  of  diabetes  is 
usually  due  to  tuberculosis  of  the  lungs,  supervening  upon  a 
prolonged  bronchial  catarrh. 

The  origin  of  the  excess  of  sugar  in  the  blood  in  diabetes 
is,  unfortunately,  as  yet  involved  in  doubt.  The  oldest  and 
most  plausible  theory  attributes  it  to  "non-combustion"  of 
the  carbo-hydrates  which  have  been  introduced  by  the  mouth 
and  to  the  "  hoarding  up  of  the  same  in  the  blood."  This  is, 
however,  an  insufficient  explanation,  because  the  sugar  forma- 
tion and  excretion  cannot  always  be  obviated  by  resorting  to  a 
meat  diet.  In  support  of  this  hypothesis,  it  is  noticeable  that 
when  the  patient  has  taken  much  sugar  and  other  carbo- 
hydrates there  is  a  perceptible  increase  of  sugar  in  the  urine, 
while  a  pure  diet  of  meat  produces  a  decrease  in  the  same. 
This  fact  is  at  any  rate  plainly  evinced,  that  from  whatever 
source  the  sugar  is  supplied  to  the  blood  in  diabetes,  there  is 
an  incapacity  to  utilize  it  properly. 

It  appeared  at  one  time  as  though  the  diabetic  centre  dis- 


DISTURBANCES   IN   BLOOD-PURIFICATION.  145 

covered  by  Cl.  Bernard,  and  his  investigations  concerning 
glycogen  in  the  liver,  were  on  the  point  of  clearing  up  this 
difficult  problem.  But  it  has  been  proved  (1)  that  the  temporary 
diabetes,  as  well  as  the  other  heterogeneous  phenomena,  pro- 
duced by  irritation  of  the  diabetic  centre,  is  not  identical  with 
the  permanent  diabetes  of  glucosuria ;  (2)  that  glycogen,  about 
which,  following  the  initiative  of  the  French  investigator, 
countless  experiments  have  been  made,  does  not  exist  alone 
in  the  liver,  but  in  almost  all  parenchyma,  especially  in  the 
muscles ;  furthermore,  that  it  is  a  product  of  the  splitting  up 
of  albumen,  occupying  in  this  respect  a  position  similar  to 
that  of  fat,  and  that  these  two  substances  in  their  deposition 
and  subsequent  use  present  much  that  is  analogous. 

As  to  the  practical  gain  from  this  discovery,  it  teaches  us 
at  most  to  assume  that  there  is  in  diabetes  mellitus  an  ex- 
cessive consumption  of  bodily  albumen,  and  that  the  disin- 
tegration of  the  latter,  with  the  probable  assistance  of  glycogen, 
forms  the  sugar.  In  order  to  understand  this  storing  up  of  sugar 
in  the  blood,  we  must  supplement  the  above  assumption  by 
still  another,  viz.,  that,  for  reasons  as  yet  totally  unknown, 
the  diabetic  patient  is  unable  to  assimilate  in  a  physiological 
manner  the  sugar  which  has  accumulated  in  the  blood.  Lest 
this  lack  of  adaptability  should  suggest  "  non-combustion," 
we  must  bear  in  mind  that  there  are  still  other  metamorphoses 
of  sugar  known  to  us,  and  we  must  also  be  cautious  about  at- 
tributing the  supposed  non-combustion  to  an  imperfect  supply 
of  oxygen. 

A  certain  amount  of  acetone  has  been  recently  proved  to 
exist  in  the  urine  of  diabetes  mellitus.  Urine  containing 
acetone  exhibits,  upon  the  addition  of  the  chloride  of  iron,  a 
dark  red  coloration.  The  presence  of  acetone  in  the  urine 
presupposes  it  also  in  the  blood,  constituting  acetonsemia, 
although  disturbances  especially  characteristic  of  acetonsemia 
are  not  known. 

(d)  Uric  Acid  Diathesis. 

We  have  found  the  phenomena  of  diabetes  mellitus  to 
centre,  not  in  the  saccharine  urine,  but  in  the  blood  con- 
taining saccharine  matter.  This  is  equally  true  of  what  is 
known  as  uric  acid  diathesis. 

Uric  acid  is  a  product  of  urinary  excretion,  which  is 
more  or  less  largely  secreted  according  to  individual  con- 


146  GENERAL   PATHOLOGY. 

ditions  which  are  very  imperfectly  understood.  As  the  ex- 
cretion of  uric  acid  in  certain  animals  takes  the  place  of  that 
of  urea  in  man,  there  appears  to  exist  a  certain  "supple- 
mentary" relation  between  them.  Such  a  relationship  could 
be  easily  interpreted  if  we  were  able  to  prove  that  the  uric 
acid  is  converted  within  the  body,  sometimes  in  a  greater, 
sometimes  in  a  lesser  degree,  into  urea.  Outside  of  the  body, 
indeed,  we  are  able  to  resolve  uric  acid  into  urea  and  such 
substances  as  may  be  considered  urea,  and  in  which  certain 
hydrogen  atoms  are  represented  by  acid  radicles.  But  it  has 
not  yet  been  established  that  uric  acid  is  also  converted  into 
urea  within  the  body.  It  seems  rather  to  be  of  extreme 
stability  and  to  be  thrown  off  finally  only  as  uric  acid.  This 
fact,  on  account  of  its  insolubility,  leads  to  peculiar  phe- 
nomena, which  progress  from  a  condition  of  perfect  health  up 
to  the  most  aggravated  diseased  states. 

The  "over  production"  of  uric  acid  either  during  or  after 
a  fever  is  well  established.  The  sedimentum  lateritium  (brick- 
dust  sediment),  consisting  of  sodium  urate,  is  well  known  in 
the  cooled  urine  of  fever  patients.  Again,  this  over-production 
of  uric  acid  appears  among  people  who  have  been  subject  all 
their  life  to  rheumatic  fevers,  so  that  it  would  seem  as  though 
certain  cell  districts  of  the  organism  (brain,  spleen  ?)  persisted 
in  the  over-production  of  uric  acid  as  a  bad  habit  contracted 
during  fever.  Another  cause,  which  is  still  more  important 
and  widely  prevalent,  is  the  habitual  use  of  alcoholic  drinks 
and  excessive  consumption  of  meat.  Still  the  origin  of  uric 
diathesis  is  not  entirely  clear.  With  many  it  is  heredi- 
tary, and,  once  acquired,  reappears  with  stubborn  persistency 
from  one  generation  to  another. 

There  is  but  one  mode  of  escape  for  this  superabundance  of 
uric  acid.  Like  the  normal  uric  acid,  it  must  be  extracted 
from  the  blood  by  the  epithelium  of  the  uriniferous  tubules, 
must  be  mixed  with  the  secretion  of  the  kidney  and  thrown 
off  through  the  larger  urinary  passages.  Unfortunately  this 
mechanism  is  not  always  equal  to  the  task  assigned  to  it,  and 
both  the  extraction  from  the  blood  and  the  elimination  from 
the  urinary  passages  may  be  imperfectly  performed.  Hence 
we  have  gout  on  the  one  hand  and  gravel  (lithiasis)  on  the 
other,  representing  the  most  important  results  of  the  uric  acid 
diathesis. 

Gout  (arthritis)  is  a  very  painful  inflammation  of  one  or 


DISTURBANCES   IN    BLOOD-PURIFICATION.  147 

more  joints,  due  to  the  deposition  of  urate  of  sodium,  urate  of 
calcium,  or  pure  uric  acid  in  the  cartilages,  ends  of  bones, 
synovial  capsules  and  ligaments.  The  paroxysmal  recurrence 
of  gout  is  usually  assigned,  not  so  much  to  a  periodic  increase 
in  the  formation  of  uric  acid  as  to  a  periodic  decrease  in  its  ex- 
cretion from  the  kidneys.  It  almost  appears  as  though  the  renal 
epithelia  became  exhausted  by  the  continuous  and  excessive 
excretion  of  uric  acid,  and  suspended  temporarily  their 
activity,  for  it  is  a  well  established  fact  that  the  proportion  of 
uric  acid  in  the  urine  is  lessened  during  gout. 

Notwithstanding  all  this,  there  is  much  that  is  obscure  about 
the  disease.  The  deposition  of  uric  acid  in  the  joints, — tophus 
formation — is  due  chiefly  to  the  insolubility  of  the  uric  acid. 
It  is  only  soluble  as  a  basic  salt.  If  one-half  of  its  base  be 
withdrawn  by  any  acid  salt,  e.  g.,  bibasic  phosphate  of  sodium, 
there  results  a  crystalline  precipitate  of  acid  urate  of  sodium 
or  calcium.  The  question  now  arises,  in  what  degree  are 
these  conditions  fulfilled  in  the  deposit  of  the  secretion  within 
the  cartilages  of  the  joints,  etc.  ?  Is  there  an  acid  reaction 
on  the  part  of  the  nutritive  fluid  ?  Certainly  not  in  a  normal 
condition,  but  it  is  possible  that  in  the  uric  acid  diathesis,  the 
impeded  flow  of  nutritive  fluid,  especially  in  the  joints,  may 
afford  time  for  the  slightly  alkaline  fluid  to  become  completely 
acid. 

A  much  more  simple  process  is  the  formation  of  gravel  and 
calculi  in  the  urinary  passages.  The  acidity  of  healthy  urine 
is  due  to  the  acid  phosphate  of  sodium  which  it  contains. 
When,  therefore,  there  arises,  as  the  result  of  the  increase  of 
uric  acid,  a  quantitative  disproportion  between  acid  and 
base,  the  insoluble  uric  acid  precipitates  itself  in  the  urinary 
passages,  and  the  concrements  thus  formed  are  called,  accord- 
ing to  their  size,  gravel  or  calculi. 

Urinary  gravel,  or  sand,  consists  of  yellowish-brown  gran- 
ules, of  the  size  of  a  pin's  head  or  smaller,  which,  upon  ex- 
amination under  the  microscope,  prove  to  be  a  conglomeration 
of  uric  acid  crystals.  The  smallest  conglomerations  of  this 
kind  are  found  ultimately  in  the  kidneys  themselves,  especially 
in  the  broad  excretory  ducts  of  the  renal  papillae.  From  here 
they  pass  into  the  renal  calyx,  and  thence,  growing  gradually 
larger,  into  the  pelvis  of  the  kidney  and  bladder,  from  whence 
they  are  discharged.  Unfortunately  matters  do  not  always  run 
thus  smoothly.  As  the  ureters  on  the  one  hand,  and  the 


148  GENERAL   PATHOLOGY. 

urethra  on  the  other,  do  not  arise  from  the  most  dependent 
portions  of  the  pelvis  and  bladder,  both  of  the  latter  are  par- 
ticularly favorable  seats  for  the  reception  and  retention  of 
some  of  the  heavier  concrements.  Remaining  in  this  position, 
and  increased  by  new  additions  of  uric  acid  and  urate  of 
sodium,  such  a  mass  becomes,  finally,  a  large  kidney- 
or  bladder-stone,  the  natural  discharge  of  which  is  ac- 
companied with  agonizing  pain  (renal  colic),  if,  indeed,  it 
is  possible  to  discharge  it  at  all. 

(e)  Disturbances  in  the  Secretion  of  Bile.    (Icterus.    Cholcemia.) 

There  are  very  few  general  observations  to  be  made  con- 
cerning functional  disturbances  of  the  liver.  This  is  owing, 
in  the  main,  to  the  great  tenacity  of  the  hepatic  cells  in  the 
discharge  of  their  function,  even  under  the  most  unfavorable 
circumstances,  and  also  to  the  broad  underlying  basis  of  this 
function,  i.  e.,  the  abundant  blood  changes  in  the  organ.  Al- 
though an  easily  verified  fact,  it  still  seems  hardly  conceivable, 
that  the  requisite  amount  of  bile  can  be  secreted  by  a  liver 
in  which  each  separate  cell  contains  a  fat  drop,  so  large  that 
it  can  scarcely  be  encircled  by  the  normal  protoplasm,  or 
that  an  amyloid  liver  can  still  perform  its  functions  without 
possessing  a  solitary  intact  cell.  Whether  and  to  what  extent 
the  protoplasm  of  the  hepatic  cells  is  capable  of  abnormally 
increasing  its  activity,  is  a  pertinent  question.  It  is  certain 
that  when  numbers  of  liver  cells  undergo  degeneration,  as  in 
syphilitic  disease,  the  remainder  subdivide  and  thereby  avert 
the  threatening  disturbance  of  function. 

It  is  only  in  acute  yellow  atrophy  of  the  liver  that  there  is 
an  unquestionable  suppression  in  the  formation  of  bile.  Apart 
from  this  affection,  which  will  be  considered  hereafter,  the 
medical  vocabulary  defines  a  disturbance  of  the  biliary  secre- 
tion to  be  exclusively  an  impeded  discharge  of  the  bile  which 
is  already  formed,  from  the  biliary  passages  into  the  intestinal 
canal.  It  gives  the  name  of  hepatogenous  or  resorption  icterus 
to  that  dyscrasia  which  is  produced  by  the  resorption  into  the 
blood  of  the  individual  constituents  of  the  bile,  especially  the 
biliary  coloring  matter. 

The  most  frequent  cause  of  suppression  of  bile  is  a  catarrhal 
swelling  of  the  ductus  choledochus;  sometimes,  but  more 
rarely,  it  is  due  to  gall  stones  obstructing  the  lumen  of  the 
same.  The  resorption  of  the  watery  matter  of  the  bile  and 


DISTURBANCES    IN    BLOOD-PURIFICATION.  149 

the  bilirubin  contained  in  the  same,  dates  from  the  moment 
when  the  lateral  pressure  of  the  accumulated  bile  becomes 
greater  than  the  pressure  which  forces  the  lymph  current  into 
the  adjacent  lymphatics.  The  biliary  salts  are  absorbed  in 
small  quantities,  the  cholesteriu  not  at  all. 

That  this  resorption  has  taken  place  is  soon  apparent,  for 
all  the  visible  parts  of  the  body,  which  are  normally  white, 
and  the  least  colored  by  the  blood,  assume  first  a  light,  then  a 
deeper,  shade  of  yellow.  The  sclerotic  first  betrays  the  fact 
that  the  blood  serum  is  no  longer  colorless.  The  skin  then 
becomes  tinged  with  all  shades  of  yellow,  finally  becoming 
brown,  and  even  black. 

The  parenchymas  of  the  body  become,  of  course,  also 
jaundiced.  Only  nerve  tissue  and  cartilage  remain  white. 
The  passage  of  the  biliary  pigment  into  the  urine  is  of  especial 
note,  as  it  is  only  through  this  means  that  it  can  eventually  be 
removed  from  the  blood.  The  urine  becomes  dark  brown  or 
almost  black,  it  exhibits  a  yellow  froth,  and  upon  being  care- 
fully mixed  in  a  test-tube  with  strong  nitric  acid,  shows  a 
brilliant  play  of  colors  which  betrays  the  presence  of  the  biliary 
pigment. 

We  may  safely  conclude,  from  the  diminished  frequency  of 
the  pulse  in  icterus,  that  the  blood  receives  not  only  the  col- 
oring matter  but  the  biliary  salts  as  well.  These  have  also 
been  traced  in  the  urine,  although  in  such  insignificant  quan- 
tities that  we  need  feel  no  great  alarm  at  the  presence  of  sub- 
stances otherwise  so  poisonous  and  of  such  destructive  effect 
upon  the  blood  corpuscles. 

Much  more  serious  phenomena  than  those  produced  by  the 
resorption  of  the  biliary  constituents  into  the  blood,  are  caused 
by  the  accompanying  non-discharge  of  the  secretion  of  the 
liver  into  the  digestive  tract.  It  is  of  little  consequence  in 
jaundice  if  the  intestinal  contents  remain  uncolored,  i.  e.,  of  a 
clayey-white  color,  but  it  is  a  rather  more  serious  affair  when 
they  become  actually  decomposed  and  productive  of  offensive 
gases.  Gerhardt  has  discovered  in  them  enormous  quantities 
of  tyrosin  crystals.  The  bile,  we  know,  possesses  anti-putre- 
factive properties  and  aids  in  the  assimilation  of  fat.  In 
icterus,  accordingly,  the  assimilation  of  fat  is  also  impaired, 
which  undoubtedly  must  and  does  exert  a  pernicious  influence 
upon  general  nutrition. 

Ordinary  jaundice  is,  generally  speaking,  a  condition  which, 


150  GENERAL   PATHOLOGY. 

notwithstanding  some  unpleasant  features,  may  continue  for 
weeks  or  months  without  injury  and  with  a  reasonable  certainty 
of  ultimate  recovery. 

It  is  only  when  the  obstructions  of  the  ductus  choledochus 
are  unusually  firm,  obstinate  and  persistent  that  simple  cases 
of  icterus  develop  into  a  very  serious  complication  called 
icterus  gravis.  The  pulse,  which  until  now  has  been  slow, 
becomes  first  of  all  strikingly  accelerated ;  after  which  there 
follows  a  depressed,  sleepy,  and  finally  comatose  condition. 
From  time  to  time  the  patient  exhibits  restlessness  and  a 
desire  to  rise  ;  he  talks  incoherently,  and  at  last  becomes  so 
delirious  that  he  can  with  difficulty  be  held  in  bed.  Hemor- 
rhages from  the  nose  and  anus  also  take  place,  and  if  an 
autopsy  be  made  we  find  extravasations  in  many  of  the  organs, 
as  well  as  in  the  loose  connective  and  fatty  tissues,  and  in  the 
cerebral  and  serous  membranes.  There  is,  likewise,  a  fatty 
degeneration  of  the  myocardium,  of  the  renal  epithelia,  and 
especially  of  the  liver  cells,  as  far  as  they  are  visible. 

As  the  result  of  much  personal  experience,  I  do  not  hesi- 
tate to  attribute  the  cases  of  icterus  gravis  (cholsemia,  in  its 
strictest  sense),  which  have  been  developed  from  simple  icterus, 
to  a  biliary  liquefaction  of  the  liver  cells,  although  I  am  not 
as  yet  prepared  to  assert  whether  this  cholsemic  admixture  of 
the  blood  is  induced  by  resorbed  bile,  by  re-absorbed  products 
of  degeneration  of  the  liver  cells,  or  by  the  storing  up  in  the 
blood  of  biliary  constituents. 

This  precaution  is  a  necessary  one,  in  view  of  yet  another 
mode  of  origin  of  the  symptoms  characteristic  of  icterus 
gravis,  viz. :  their  appearance  in  connection  with  acute  yel- 
low atrophy  of  the  liver.  In  this  disease  there  exists  neither 
an  obstruction  of  the  biliary  passages  nor  a  preceding  stage 
of  simple  icterus.  A  man  in  perfect  health  is  suddenly  struck 
down  with  this  severe  form  of  jaundice.  In  the  few  hours 
which  elapse  before  death,  the  physician  perceives  a  distinct 
diminution  in  the  area  of  dullness  of  the  liver,  which  is  ex- 
plained by  finding  at  the  autopsy  a  marked  diminution  in  the 
size  of  the  organ,  caused  by  the  dissolution  and  resorption  of 
liver  cells.  Is  it  possible  that  there  is  here  a  resorption  of 
bile?  The  biliary  passages,  it  is  true,  are  empty,  and  contain  in 
place  of  bile  a  colorless  mucus.  We  get  the  impression  that 
they  are  empty,  because  they  have  for  a  long  time  received  no 
influx  of  bile.  In  this  case,  the  scarcely-formed  bile  must 


DISTURBANCES   IN   BLOOD-PURIFICATION.  151 

have  been  re-absorbed  from  the  intercellular  biliary  capil- 
laries— a  very  bold  hypothesis.  There  remains  then  only  the 
supposition  of  a  primary  transformation  of  the  liver  cells,  the 
nature  of  which  is  unknown  to  us.  Is  it  a. cloudy  swelling 
resulting  from  a  poisonous  inoculation,  which  is  analogous,  and 
possibly  at  times  even  identical,  with  the  action  of  phosphorus 
on  the  liver  cells  ?  We  only  know  that  the  liver  cells  degene- 
rate with  surprising  rapidity,  and  that  their  products  of  de- 
generation are  rapidly  transferred  to  the  blood.  I  am,  ac- 
cordingly, much  inclined  to  attribute  icterus  gravis  to  the 
action  of  the  re-absorbed  debris  of  liver  cells.  This  action  is 
apparent  in  one  direction  by  the  dissolution  of  numberless 
red  blood  corpuscles,  and  the  metamorphosis  of  the  liberated 
coloring  matter  of  the  blood  into  biliary  pigment ;  in  another, 
in  serious  irritation  of  the  central  nervous  system  and  the 
general  dissolution  of  the  blood,  leading  to  hemorrhage. 

In  the  present  imperfect  state  of  our  knowledge,  we  can 
neither  deny  nor  prove  that  the  formative  matter  of  the  bile, 
which  during  the  suspended  activity  of  the  liver  cells  must 
naturally  be  retained  in  the  blood,  has  some  share  in  pro- 
ducing cholsemia.  On  the  whole  we  may  conclude  that  this 
matter  is  of  a  more  harmless  nature,  such  as  albuminous 
bodies,  fat,  etc.  This  for  the  present  disposes  of  the  question  as 
to  the  existence  of  a  retention-dyscrasia  of  the  biliary  constitu- 
ents— corresponding  to  the  retention  of  urea  or  carbonic  acid 
in  lung  and  kidney  diseases — and  of  a  pollution  of  the  blood 
by  non-secretion  of  possible  "  bile-constituting"  excretory  sub- 
stances. Such  an  idea  must,  on  general  principles,  be  rejected, 
although  the  denial  in  the  case  of  the  biliary  pigment  should 
be  accepted  cum  grano  salts. 

There  is  an  abnormal  state  in  which  large  numbers  of  red 
blood  corpuscles  undergo  dissolution,  whether  as  the  result  of 
poisonous  matter  which  has  entered  the  blood  and  caused  the 
dissolution  (protoxide  of  carbon,  picric  acid,  poisonous  fungi), 
or,  as  is  oftener  the  case,  as  the  result  of  an  extensive  extrava- 
sation where  the  extravasated  blood  has  been  dissolved  out 
and  gradually  re-absorbed.  In  both  instances  the  liberated 
coloring  matter  is  often  retained  for  some  time  in  the  blood 
serum,  and  becomes  only  gradually  converted  into  biliary 
coloring  matter.  The  latter  lends  to  the  skin  and  sclerotic 
precisely  the  same  yellowish  and  brownish  hue  as  that  pro- 
duced by  the  biliary  pigment  which  is  absorbed  from  the 


152  GENERAL   PATHOLOGY. 

biliary  passages  in  "resorption  icterus."  We  have,  accord- 
ingly, some  authority  for  contrasting  this  haematogenous 
icterus  with  the  often-described  hepatogenous  form.  Bilirubin 
appears  also  in  the  urine,  and  is  generally  termed  urobilin, 
and  the  disease  designated  as  urobilinuria.  No  investigations 
of  any  note  have  as  yet  been  made  regarding  the  non-secretion 
of  this  bilirubin  by  the  liver,  although  the  question  is  probably 
within  the  range  of  experimental  investigation. 

B.  ANIMAL  DISTURBANCES. 

The  apparatus  of  animal  sensation  and  locomotion  possesses 
no  arrangement  by  which  it,  like  the  blood  in  the  vegetative 
organs,  can  generalize  every  local  change  and  sympathetically 
affect  the  entire  body.  It  consists  of  many  parts,  brought 
into  communication  with  each  other  by  nerve  fibres,  which 
unite  them  into  an  anatomical  whole.  This  connection  makes 
a  diffusion  of  local  disturbance  possible,  in  the  sense  of  ana- 
tomically-continuous sympathetic  affections.  We  have  already 
noticed,  in  the  deuteropathic  group  of  symptoms,  that  an  irri- 
tation of  a  peripheral  sensitive  nerve  may  assume  astonish- 
ing proportions,  and  it  is  self-evident  that  the  individual 
anatomico-pathological  changes  are  equally  capable  of  diffu- 
sion. In  other  words,  wounds,  inflammations,  hemorrhages, 
tumors,  etc.,  centering  in  the  nervous  system  itself,  are  able 
to  produce  symptoms  of  local  and  general  irritation  which, 
through  the  anatomical  agency  of  the  nervous  system,  may 
be  propagated  from  every  possible  seat  of  disease.  This  is, 
however,  not  our  present  point  of  view.  We  have  now  to 
consider  the  generalization  of  a  local  trouble  by  the  local 
disturbance  of  function  and  the  participation  of  the  general 
organism  in  the  same.  By  studying  the  individual  diseases 
of  the  sensory-motor  system  in  this  light,  we  shall  arrive  at 
very  different  results. 

We  are  struck,  first  of  all,  by  the  extraordinary  diversity  in 
the  operation  of  the  pathological  changes  of  the  sensory  and 
motor  apparatus  upon  the  general  organism.  Their  value  and 
significance  depend  partly  upon  the  locality  which  is  attacked, 
partly  upon  the  manner  in  which  it  is  attacked.  The  slightest 
change  in  the  floor  of  the  fourth  ventricle  may  produce  an 
instantaneous  stoppage  of  respiration  and  death  by  asphyxia. 
Equally  dangerous  are  all  the  acute  exudations  into  the  ven- 
tricles and  sub-arachnoid  spaces  of  the  cerebrum,  and  also 


ANIMAL    DISTURBANCES.  153 

hemorrhages  which  lead  to  extensive  destruction  and  com- 
pression of  the  organ  attacked. 

On  the  other  hand,  the  brain  possesses  an  unusual  power  of 
accommodation  for  all  small  and  slowly-increasing  pathological 
effusions  and  new  formations.  And  not  in  the  brain  alone,  but 
in  the  entire  sensory-motor  apparatus,  do  we  find  a  thorough 
development  of  the  principle  of  vicarious  performance  of 
function.  Accordingly,  when  a  local  trouble  does  not  at 
once  produce  death,  we  may  be  prepared  to  see  it  last  for 
some  time. 

This  latter  fact  explains  why  diseases  of  the  sensory-motor 
apparatus  ^appear  to  be  of  less  intense  interest  to  a  physician 
than  those^affections  of  the  vegetative  organs  which  place  the 
life  of  the  patient  in  more  immediate  jeopardy,  although 
there  is,  undoubtedly,  no  other  branch  of  pathology  which 
offers  to  the  thoughtful  student  a  richer  field  for  sagacious 
deliberation  and  diagnosis. 

The  groups  of  symptoms  may  be  subdivided  into  those  con- 
cerned (1)  with  the  phenomena  of  anatomical  change,  (2)  with 
the  disturbances  of  function,  produced  by  the  same,  (3)  with 
the  vicarious  functions  themselves.  These  three  divisions, 
studied  as  a  whole,  present,  we  may  truly  say,  a  mathemati- 
cally correct  and  characteristic  expression  of  the  disease,  and 
one  which  is  applicable  to  each  part  of  the  apparatus.  Yet 
how  difficult  it  is,  in  many  cases,  to  analyze  and  define, 
not  only  the  nature,  but  also  the  seat  of  the  disease!  And 
it  is  these  two  points,  as  we  have  said,  which  are  of  prime 
importance  in  estimating  the  pathological  value  of  every 
lesion. 

In  considering  the  seat  of  disease,  we  must  recollect  that 
the  various  members  of  the  sensory-motor  apparatus  are  com- 
bined into  a  harmonious  whole.  Thus,  the  pathological  symp- 
toms which  come  under  our  notice  are,  equally  with  the  normal 
symptoms  of  the  apparatus,  the  external  manifestations  of  an 
extended  or  limited  series  of  phenomena,  which  have  been 
propagated  through  legitimate  paths  from  the  seat  of  disease. 
The  fact  that  a  joint  sometimes  remains  immovably  flexed 
may  be  due  to  various  causes :  (1)  to  a  degeneration  of  the 
joint  itself,  (2)  to  a  contraction  of  the  flexor  muscles,  (3)  to 
an  irritation  of  the  motor  nerves  belonging  to  these  muscles, 
(4)  to  centric  disease,  which  is  either  situated  at,  or  acts  upon, 
the  centre  where  these  nerves  originate.  Many  other  causes 
ii 


1     154  GENERAL  PATHOLOGY. 

1  might  be  enumerated.  It  is  easily  possible  that  such  a  con- 
traction might  be  produced  by  reflex  action  of  a  peripherally- 
irritated,  sensitive  nerve,  as  we  often  see  in  hysteria.  Gen- 
erally, however,  we  do  not  go  so  far  out  of  our  way,  but 
content  ourselves  with  establishing  a  very  sharp  division 
between  centripetal  and  centrifugal  phenomena.  This  dis- 
tinction is  especially  of  value  in  view  of  the  fact  that  in  all 
the  larger  animals,  as  well  as  in  man,  there  is  in  the  brain  a 
marked  capacity  for  receiving  and  retaining  impressions  trans- 
mitted from  without.  Accordingly,  in  people  gifted  with 
unusual  brain  power,  the  majority  of  these  impressions  ter- 
minate, for  the  time  being,  in  the  brain.  Does  not  the  entire 
psychical  life  of  man  depend  upon  this  mediatorial  office  of 
the  brain,  with  its  retarding  influence  upon  the  processes  of 
sensation  and  motion  ?  What  we  call  mental  faculties  are 
merely  the  different  divisions  of  the  road  which  leads  into, 
through,  and  again  away  from  the  brain.  These  divisions  are 
centres  which  are  neither  purely  sensory  nor  purely  motor. 
They  represent,  rather,  various  transitions  and  mixtures  of 
sensation  and  motion,  which  we  call  perception,  imagination, 
fancy  and  will.  In  perception,  the  motory  element  is  the 
weakest,  the  sensory  the  strongest.  This  is  reversed  in  will, 
while  in  imagination  the  active  and  passive  preponderate 
alternately. 

The  brain,  therefore,  with  all  its  individual  functions,  occu- 
pies the  middle  ground  between  the  centripetal  and  centrifugal 
phenomena.  This  circumstance,  while  it  justifies  a  marked 
distinction  between  the  two,  necessitates  at  once  an  especial 
category  for  the  psychical  disturbance  of  function. 

To  establish  the  nature  of  disease  is  another  task  which  pre- 
sents far  more  difficulties  in  the  realm  of  the  sensory-motor 
apparatus  than  elsewhere.  The  number  of  pathologico-ana- 
tomical  changes  occurring  here  is  unusually  large.  We  meet 
with  acute  and  chronic  inflammations,  and  with  tumors  of 
every  variety,  both  in  the  brain  and  spinal  marrow  and  in  the 
peripheral  nervous  system.  In  vivid  contrast  with  this  multi- 
plicity is  the  unvaried  monotony  of  symptomatic  expression, 
arising  very  naturally  from  the  uniform  aim  of  the  system  to 
produce  either  sensation  or  motion.  In  these  two  directions, 
therefore,  and  only  in  these  two  directions,  we  may  see  the 
effects  of  functional  disturbances ;  and  all  anatomical  changes, 
call  them  what  you  will,  produce  exclusively  motor  or  sensory 


ANIMAL   DISTURBANCES.  155 

disturbances.     It  is  impossible  to  judge  from  the  quality  of 
the  functional  disturbance  of  the  quality  of  the  disease. 

There  is  still  another  consideration.  Within  the  range  of 
the  sensory-motor  disturbances  we  may  perceive  conditions  of 
abnormally  increased  and  abnormally  diminished  activity  ;  on 
the  one  hand  hypercesthesia,  and  hypcesthesia,  on  the  other, 
hyperdnesia  and  hypocineda.  A  closer  study  of  these  four 
elementary  forms  of  animal  groups  of  symptoms  is  next  neces- 
sary. It  would  appear  as  if  with  the  aid  of  this  classification 
we  might  perhaps  establish  a  qualitative  diagnosis.  But  such 
is  not  the  case.  Most  of  the  local  affections  of  the  sensory- 
motor  apparatus  produce,  first  of  all,  a  slight  injury,  which, 
acting  as  an  irritant,  produces  in  the  sensitive  nerve  fibres 
an  abnormally  increased  or  unnatural  sensation,  and  in 
the  motor  nerves  convulsions  and  contractions.  Letting  the 
matter  rest  here,  we  see  that  the  severest  functional  disturb- 
ances, the  most  terrible  convulsions  and  neuralgias,  are  caused 
by  anatomical  changes  so  slight  as  to  be  indistinguishable, 
and  we  are  thus  forced  to  concede  the  existence  of  neuroses 
sine  materie.  But  we  find  instances  where  the  anatomical 
disorder  assumes  constantly  increasing  proportions,  and  is 
more  and  more  prejudicial  to  the  performance  of  the  functions. 
We  then  see  plainly  how  the  phenomena  of  abnormal  irrita- 
tion pass  into  those  of  paralysis,  and  how  a  disease  which  in  its 
early  stages  caused  pain  and  convulsions  now  deteriorates 
into  anaesthesia  and  paralysis.  Thus  we  lose  still  another 
diagnostic  prop,  and  the  cases  are  in  the  minority  in  which, 
by  the  growth  of  anatomical  changes,  there  is  a  sudden  and 
abrupt  arrest  of  function,  a  condition  which  renders  diagnosis 
materially  easier. 

It  is  not  entirely  satisfactory  to  apply  the  term  "sympa- 
thetic," which  signifies  an  involved  condition  of  the  entire 
organism,  to  the  sensory-motor  group  of  symptoms,  because 
the  importance  of  the  diseased  spot  in  relation  to  the  general 
organism  is  so  very  varied.  It  cannot  be  denied  that  severe 
injuries  of  the  brain  and  spinal  cord,  reacting  upon  the  circu- 
lation and  respiration,  bear  this  general  character.  And  the 
less  severe  cases  may  also  be  construed  as  functional  disturb- 
ances of  the  whole  body.  Such  a  conclusion  finds  abundant 
anatomical  support  in  the  universality  of  the  nervous  system, 
and  the  intimate  connection  between  all  parts  of  the  body 
established  by  the  same. 


156  GENERAL  PATHOLOGY. 

The  term  "  typical "  has  a  different  application.  Here  we 
must  recollect  that  the  symptomatic  picture  which  betrays  a 
local  affection  of  the  sensory-motor  apparatus  corresponds 
exactly  to  the  intensity  and  extent  of  the  disease,  and  is 
characteristic  of  the  same.  But  under  the  head  of  typical 

troups  of  symptoms,  i.  e.,  those  recurring  frequently  and  uni- 
>rmly,  we  can  only  class  the  general  phases  of  irritation  and 
paralysis,  which  appear  in  the  centripetal  parts  of  the  appa- 
ratus as  hypersesthesia  and  hypsesthesia,  in  the  centrifugal 
as  hyperciuesia  and  hypocinesia,  in  the  brain,  as  psychical 
irritation  and  paralysis.  An  appendage  to  these  is  found  in 
the  neuro-vegetative  disturbances,  which  represent  irritated 
and  paralyzed  conditions  of  that  part  of  the  nervous  system 
which  projects  into  the  vegetative  system. 

Before,  however,  proceeding  to  the .  special  consideration  of 
these  four  species,  we  must  throw  a  cursory  glance  upon  a 
further  peculiarity  of  all  nervous  symptoms,  and  one  which 
has  already  been  alluded  to  (p.  84),  viz. :  periodicity  and 
the  disproportion  between  cause  and  effect.  It  is  "the  in- 
clination to  recurrence  of  a  condition  of  excitation  which  has 
several  times  existed,"  which,  once  established,  becomes  habit- 
ual, and,  independent  of  the  permanent  irritative  cause,  gives 
rise  to  a  group  of  symptoms  by  which  an  independent  heredi- 
tary disease  is  established. 

If  we  are  willing  to  admit  that  the  vital  substance  contains, 
besides  assimilation  and  sensibility,  still  another  fundamental 
element,  it  is  undoubtedly  memory,  recollection.  Every  move- 
ment of  protoplasm  is  more  easily  executed  the  second  than 
the  first  time.  It  thus  appears  that  there  are  certain  regula- 
tions of  matter  which  arise  in  order  to  facilitate  the  first  move- 
ments and  which  remain  in  force  for  some  time,  and  become 
more  and  more  established  in  proportion  as  their  activity  is 
called  into  play. 

It  is,  of  course,  not  my  purpose  to  discuss  this  momentous 
principle  which  plays  so  important  a  part  in  Darwin's  evolu- 
tion theory.  It  is  sufficient  here  merely  to  call  attention  to 
the  fact  that  in  the  individual  only  the  faculty  of  memory 
residing  in  the  central  nervous  system  is  involved.  The 
delicate  fibrous  nervous  network  of  the  gray  substance  must 
be  regarded  as  the  anatomical  substratum,  which,  in  its 
delicate  construction,  accommodates  itself  to  the  often  repeated 
impulses  constantly  passing  through  it,  until  it  finally  re- 


HYPER^ESTHESIA.  157 

produces  them  involuntarily  upon  the  slightest  provocation. 
The  smoother  the  path,  the  easier  the  traveling. 

The  point  is  at  last  reached  where  the  action,  having 
become  habitual,  appears  spontaneous,  and  the  trifling  incite- 
ment which  has  caused  it  entirely  eludes  our  observation. 
It  is,  in  truth,  of  very  little  consequence  from  what  quarter 
the  slight  impulse  comes.  It  is  unimportant  whether  the 
ripe  fruit  has  been  shaken  from  the  tree  by  a  child  or  by  the 
motion  of  the  wind.  It  is  the  result  alone  which  concerns  us. 

This  relative  separation  between  the  phenomenon  and  its 
cause  becomes  a  "habit"  of  the  nervous  system,  which,  asso- 
ciated with  diseased  processes  of  sensation  or  motion,  is  entitled 
to  be  called  a  "  bad  habit."  It  has  become  a  fixed  function 
of  the  central  nervous  system,  which,  by  frequent  repetition, 
grows  more  and  more  persistent,  and  assumes,  when  repeated 
as  local  outbreaks,  the  form  of  an  independent  disease — in 
short,  a  neurosis 

When  we  come  to  consider  in  the  Special  Part  those  diseases 
which  arise  by  "pathological  development,"  we  shall  have 
occasion  to  refer  the  "  heredity "  of  disease  to  the  singular 
stamp  imprinted  upon  all  protoplasm,  in  especial  that  of  the 
central  nervous  system,  by  an  abnormal  and  habituated  ac- 
tivity. In  this  connection  we  shall  also  discuss  the  heredity 
of  neuroses. 

HYPER^STHESIA. 

As  sensibility  is  a  function  of  the  central  nervous  system, 
and  especially  of  the  gray  matter  of  the  cerebro-spinal  system, 
it  is  natural  that  an  excess  of  sensibility  or  lack  of  the  same, 
should  be  due  to  the  excess  or  lack  of  those  changes  in  the 
gray  matter  which  accompany  those  functions  and  make  us 
conscious  of  sensation. 

Confining  ourselves  first  to  the  excess  of  sensibility,  to  hy- 
persesthesia  in  its  broad  meaning,  we  find  that  we  are  already 
familiar  with  its  chief  appearance,  viz.,  pain,  which  is  produced 
by  the  peripheral  irritation  of  sensitive  nerves  (p.  87). 

It  is  likely  that  all  nerve  fibres  which  are  functionally  re- 
lated have  a  common  origin  in  the  central  gray  substance, 
which  is  distinguished  by  a  more  dense  accumulation  of  gan- 
glion corpuscles.  The  so-called  centres  of  origin  of  the  brain 
nerves  are,  for  the  most  part,  well-known.  But  upon  careful 
examination  and  comparison  of  sections  taken  from  different 


158  GENERAL   PATHOLOGY. 

parts  of  the  spinal  marrow,  we  are  inclined  to  admit  the  ex- 
istence of  "centres"  for  the  spinal  nerves  as  well,  which  vary 
in  length  and  extent,  according  to  the  size  of  the  organ  sup- 
plied. If  this  is  correct,  we  may  infer  that  the  sensation  of 
pain,  apart  from  its  later  diffusion  throughout  the  central 
nervous  system,  consists,  first  of  all,  in  an  abnormal  excitation 
of  the  centre  of  origin  of  a  closely-related  group  of  sensitive 
nerve  fibres.  Whether  the  irritation  of  the  nerve  fibres  occurs 
actually  at  their  peripheries,  or  at  some  point  of  their  course, 
is  really  of  small  importance.  The  manner  of  the  irritation 
determines  the  character  of  the  pain,  in  all  its  varied  forms, 
pricking,  throbbing,  lancinating,  etc.  The  intensity  of  the 
pain  is  likewise  graded  according  to  the  various  causes.  The 
seat  of  the  pain  is,  however,  invariably  situated  at  the  peri- 
pheral terminations  of  the  irritated  nerve-fibres. 

We  may  even  go  so  far  as  to  assert  that  the  diseased  irrita- 
tion of  the  central  nerve  nucleus  is  also  consciously  transferred 
to  the  periphery,  even  when  the  frritation  is  not  produced  by 
the  centripetal  nerve  fibres  (law  of  eccentric  projection). 
The  central  nerve  nucleus  may  also,  as  we  know,  be  irritated 
by  diseased  conditions  of  the  brain  or  spinal  marrow,  of  which 
it  forms  an  integral  constituent ;  thus,  it  is  very  plain  that  we 
ought  to  distinguish  these  pseudo-peripheral  sensations,  which 
are  in  reality  central,  from  those  which  are  generally  peri- 
pheral. 

Over-sensibility,  or  hypersesthesia,  is  not,  strictly  speaking, 
real  pain.  It  is  a  certain  additional  mobility  of  the  whole  or 
a  part  of  the  sensory  apparatus,  by  virtue  of  which  very 
trifling  irritations  are  enabled  to  produce  acute  sensations. 
In  fever  we  find  a  general  and  frequently  occurring  hyper- 
sesthesia, which  is  rarely  lacking  when  the  fever  is  at  its 
highest. 

There  are  also  local  hypersesthesias  which  are  situated  in 
the  peripheral  ramifications  and  terminations,  as  well  as  in 
the  centres  of  origin  of  individual  sensitive  nerves. 

Neuralgia. 

Local  hypersesthias  especially  invite  our  attention,  because 
they  furnish  the  ba&is  for  a  very  important  variety  of  over- 
sensitiveness,  viz.,  neuralgia. 

By  neuralgia  we  mean  an  acute  pain  which  attacks  the 
trunk  and  all  the  ramifications  of  a  given  nerve  in  an  inter- 


ANESTHESIA.  159 

mittent  and  irregularly  recurring  manner.  The  pain  is  felt 
along  the  entire  course  of  the  nerve,  although  there  are  certain 
spots  known  as  pain  centres.  These  are  fixed  undoubtedly 
by  the  anatomical  construction  of  the  nerve  trunks,  as  they  are 
generally  the  same  in  each.  Like  every  other  violent  pain, 
neuralgia  affects  sympathetically  the  sensory-motor  and  neuro- 
organic  apparatus.  Its  effect  upon  the  latter  will  again  engage 
our  attention  when  we  come  to  speak  of  trophoneurosis. 

Leaving  out  of  the  question  the  great  number  of  predis- 
posing influences,  conspicuous  among  which  is  heredity,  we 
may  define  neuralgia  to  be  the  result  of  a  persistent,  uniform, 
although  not  always  powerful,  excitation  of  that  point  in  the 
brain  or  spinal  marrow  where  the  nerve  in  question  originate?. 
Whether  the  excitation  comes  from  without,  or  is  produced 
internally,  is  of  small  consequence  in  the  symptomatic  picture. 
After  it  has  existed  for  some  time,  an  over-sensitive  condition 
sets  in,  in  the  shape  of  slight  pricking  and  throbbing,  the  pre- 
monitors  of  pain,  after  which  the  first  neuralgic  attack  ensues. 
Thus  the  gradually  habituated  excess  of  sensibility  is  con- 
verted into  a  permanent  and  periodically  recurring  function 
of  the  gray  matter,  a  neurosis  of  sensibility. 

By  molecular  lacerations  (nerve  stretching),  or  cutting  out 
portions  of  the  nerves  along  whose  paths  the  neuralgia  is 
situated,  we  can  temporarily  arrest  the  physiological  centripe- 
tal irritation,  and  thus  proportionally  lessen  the  irritated  con- 
dition of  the  nerve  nucleus.  The  probability  of  a  permanent 
cure  depends  upon  the  nature  and  seat  of  the  cause  of  dis- 
ease. 

ANESTHESIA. 

Almost  all  the  organs  in  a  healthy  body  are  entirely  devoid 
of  sensation,  or  we  realize  at  most  their  presence  in  an  indefi- 
nite and  vague  manner.  A  further  diminution  of  sensation, 
or  its  complete  absence,  can,  therefore,  not  be  interpreted  as 
disease. 

Only  the  skin  and  the  adjacent  portions  of  the  mucous 
membrane  constantly  convey  to  our  consciousness  impressions 
which  we  are  accustomed  to  class  with  the  perceptions  of  the 
higher  senses,  calling  them  sensations  or  feelings.  It  is  the 
diminution  or  absence  of  these  which  give  rise  to  anaesthesia. 
Defects  of  sight,  hearing,  taste  and  smell,  belong,  strictly 
speaking,  also  to  the  anaesthesias,  but  it  is  customary  to  classify 


160  GENERAL  PATHOLOGY. 

blindness  and  deafness,  at  least,  separately,  while  cases  of 
anosmia  (loss  of  smell)  and  ageusia  (loss  of  taste)  are  so 
rare  as  scarcely  to  merit  a  detailed  description. 

Anaesthesia  is  the  typical  symptomatic'  expression  of  an 
abatement  of  function  in  the  sensibility  of  the  skin  and  other 
membranes.  Physiology,  as  we  know,  subdivides  this  exten- 
sive territory  into  the  sense  of  touch,  feeling  of  pressure,  per- 
ception of  heat,  and  also  the  sense  of  locality,  whenever  a 
definite  irritant  acts  upon  the  skin.  Many  ingenious  methods 
have  been  employed  in  order  to  ascertain  the  degree  of  acute- 
ness  of  the  skin  in  different  cases  of  anaesthesia. 

The  sensation  of  touch  is  tested  by  the  slightest  touch  applied 
to  the  skin,  that  of  feeling  by  applying  small  weights  or  the  "  ba- 
rsesthesiometer ; "  that  of  temperature  by  the  use  of  differently 
heated  plates  of  metal  or  the"  thermaesthesiometer ; "  and  lastly, 
that  of  locality  by  Weber's  calipers.  We  find  by  these  experi- 
ments that  the  different  varieties  of  membranous  sensibility  do 
not  always  diminish  uniformly,  although  generally  they  do. 

A  person  suffering  from  anaesthesia  of  the  skin  is  generally 
conscious  of  "  numbness  and  formications."  He  does  not  feel 
the  contact  of  his  body  with  his  clothes,  nor  of  his  fingers 
with  any  object  which  they  may  grasp.  In  locomotor  ataxia, 
where  the  lower  extremities  are  perceptibly  paralyzed,  the 
patient  feels  in  walking  as  though  he  were  treading  upon  air, 
so  that  his  eyesight  is  in  constant  requisition.  In  addition  to 
these  purely  negative  phenomena,  we  have  usually  those 
pricking  sensations  of  formication  and  itching  (paraesthesias), 
which  penetrate  the  paralyzed  sensibilities  like  electric  shocks, 
acting  as  very  imperfect  and  unwelcome  representatives  of 
normal  perception.  The  general  sensitiveness  of  the  skin  is 
also  implicated  in  the  impairment  of  the  senses.  The  anaes- 
thetic organ  is  more  or  less  incapable  of  experiencing  pain 
(analgesia),  and  is  insensible  to  pin  pricks,  burning,  pinching 
or  electrical  irritation.  On  the  other  hand,  we  not  rarely  find 
cases  of  anaesthesia  dolorosa,  i.  e.,  disturbances  in  the  course 
of  certain  sensitive  nerves,  caused  chiefly  by  tumors,  where 
there  is  a  growing  and  finally  complete  paralysis  of  sensation, 
alternating  with  periodic  attacks  of  violent  pain. 

In  conclusion,  I  will  allude  to  a  series  of  trophical  disturb- 
ances resulting  from  anaesthesia,  and  which  we  shall  consider 
hereafter  in  connection  with  trophoneurosis,  paralysis  after 
neurotomy,  etc. 


HYPERCINESIA — CONVULSIONS.  161 

The  chief  cause  operating  to  produce  anaesthesia  is  the  ana- 
tomical oppression  of  the  central  receptive  organs  by  all  sorts 
of  local  changes,  inflammations,  degenerations,  atrophies  and 
tumors  of  the  brain  and  spinal  cord.  The  minor  causes  are 
the  rarer  but  very  diverse  disturbances  in  the  peripheral 
radiations  of  the  sensitive  nerves,  such  as  the  extremes  of 
temperature,  caustics,  traumata,  pressure  upon  nerve-trunks, 
etc. 

HYPERCINESIA— CONVULSIONS. 

In  studying  the  construction  and  functions  of  the  sensory- 
motor  apparatus  in  different  animals,  we  shall  find,  I  believe, 
that  the  great  progress  from  lower  to  higher  life  is  due  to  the 
constantly-increasing  ascendancy  of  the  segments  of  the  brain 
over  those  of  the  body,  the  functional  independence  of  the 
latter  being  limited  by  the  former,  which  constantly  absorbs 
a  large  share  of  segmented  excitation,  and  confines  the  direct 
control  of  the  same  to  a  segmental  centre.  The  subordination 
of  the  segmental  centres  to  the  brain  finds  the  fullest  develop- 
ment in  man.  Reflex  action,  the  last  remaining  vestige  of 
the  autonomy  of  the  segmental  centre,  is  here  represented  in 
its  weakest  form.  The  only  noticeable  exceptions  to  this  rule 
are  the  centres  of  automatic  movement,  respiration,  heart's 
action,  contraction  of  the  iris,  etc.  This  is,  however,  easily 
accounted  for  by  the  constancy  and  uniformity  of  the  pro- 
ducing cause.  The  periodical  functiopal  irritability  is  forced 
to  yield,  and  we  see,  as  the  result  of  the  compromise,  the  well 
known  rhythm  of  the  pulse  and  respiration. 

Leaving  the  automatic  movements  out  of  the  question — a 
thing  we  can  the  more  readily  do,  as  they  are  pre-eminently 
a  part  of  organic  man — the  main  point  remains  unaltered, 
viz.,  that  in  man  the  sensitive  centres  of  the  spinal  cord  yield 
up  a  large  part  of  their  excitation  to  the  brain,  where  it  is 
transformed,  and  either  no  motor  expression  at  all  is  given  off, 
or  it  manifests  itself  at  some  other  point.  Thus,  under  ordin- 
ary circumstances,  the  principles  governing  the  local  connec- 
tion between  the  sensitive  and  motor  division  of  the  same 
centre  are  almost  wholly  abolished. 

A  higher  secondary  effect  of  this  anatomical  centralization 
of  the  nervous  system  is  the  well-known  consciousness  of  in- 
dividuality. 'The  power  of  the  brain  to  retain  the  centripetal 
emotions  which  reach  it,  and  either  convert  them  into  action 


162  GENERAL   PATHOLOGY. 

or  suppress  them,  appears  to  us  as  the  leading  characteristic 
of  our  own  individual  will,  the  expression  of  that  free  power 
of  volition  which  underlies  all  law  and  nature.  Natural 
philosophy  readily  accords  to  the  will  the  sovereignty  over 
the  chief  muscles  of  the  body,  and  pathology,  in  particular, 
looks  upon  a  muscular  contraction  which  takes  place  against 
the  will  as  the  first  undoubted  sign  of  disease.  Such  con- 
tractions, which  differ  from  voluntary  movements  in  their 
aimlessness  and  unnecessary  exercise  of  strength,  are  termed 
"  twitchings,"  or  "  convulsions."  In  other  respects  their  man- 
ner of  experience  is  exceedingly  dissimilar.  The  ancient 
classification  of  convulsions  is  into  tonic  and  clonic.  A  tonic 
spasm  is  a  single,  prolonged,  violent  and  often  painful  con- 
traction, in  which  the  muscles  are  stiff,  board-like  and  rigid. 
Clonic  spasms  are  contractions  which  follow  each  other  in 
quick  succession,  either  in  individual  or  collective  groups  of 
muscles. 

Tonic  convulsions  are  subdivided  into:  (1)  cramps,  which 
attack  a  muscle  or  muscles  for  a  short  space  of  time  (bather's 
cramp) ;  (2)  tetanus,  which  extends  over  almost  the  entire 
muscular  system  (p.  89) ;  (3)  fiexibilitas  cerea,  which  ex- 
hibits all  the  muscles  in  a  moderately  contracted  condition, 
and  the  antagonistic  ones  with  a  complementary  increase  of 
nervous  power,  so  that  a  position  once  forced  upon  the  patient 
is  inflexibly  retained ;  (4)  contracture  and  painful  and  fre- 
quently permanent  rigidity  of  a  muscle  or  muscles,  terminat- 
ing at  last  in  atrophy. 

Clonic  convulsions,  which  are  classified  according  to  the 
number  and  force  of  the  involuntary  movements,  present  an 
ascending  scale  of  varieties,  from  trembling  (tremor),  shaking 
(agitatio),  knocking  together  of  the  limbs,  involuntary  gri- 
maces when  the  convulsions  affect  the  facial  muscles,  up  to 
the  most  aggravated  form  of  convulsive  contractions  of  the 
entire  body  and  horrible  facial  distortions. 

Let  us  now  inquire  into  the  causes  which  produce  convul- 
sions. The  first  of  these  is,  naturally,  the  weakening  of  the 
incomparable  mastery  wielded  by  the  brain  over  the  incoming 
and  outgoing  sensibilities  of  the  nervous  system.  This  is  the 
only  explanation  of  the  "  suspension  of  consciousness  "  which 
we  find  in  epilepsy  and  other  severe  convulsions.  The  actual 
sources  of  this  weakening  are  not  definitely  known.  In  many 
instances  it  is  chargeable  to  a  natural  imperfection  of  the 


HYPERCINESIA — CONVULSIONS.  163 

brain,  due  either  to  inheritance  or  disturbed  development ;  in 
others,  again,  it  is  an  acquired  anomaly,  an  intercranial  in- 
flammation or  tumor,  it  may  be,  which  has  deprived  the  brain 
of  its  restraining  power  over  the  conditions  of  excitement. 

To  produce  these  convulsions,  which  have  their  centre  in 
the  brain,  does  not  require,  as  a  general  thing,  any  strong, 
centripetal  irritation  of  this  organ.  The  physiological  irrita- 
tions to  which  it  is  exposed  are  abundantly  sufficient.  This 
does  not,  however,  apply  to  that  variety  of  convulsions  which 
originates  within  or  without  the  brain — regarding  the  sensory- 
motor  apparatus  as  a  whole — to  what  are  known  as  direct  and 
reflex  convulsions.  Muscular  contractions  produced  by  direct 
irritation  of  a  muscle  or  a  motor  path,  outside  of  the  brain 
and  spinal  marrow,  are  generally  of  a  tonic  character.  If  the 
irritation  attack  a  mixed  nerve  trunk  it  will  be  accompanied 
by  corresponding  sensitive  and  other  disturbances.  It  is, 
however,  worthy  of  note  that  the  motor  nerve  fibres  are  not 
capable  of  offering  much  resistance  to  the  irritation  just  men- 
tioned, so  that  a  convulsion  is  very  soon  converted  into  a 
paralysis.  This  is  especially  true  of  all  mechanical  irritations. 
A  prolonged  convulsion  is  much  more  likely  to  be  produced 
by.  a  cumulative  inflammatory  process,  discerned  by  the 
pathologico-anatomist  with  difficulty,  as  a  slightly  overgrown 
nucleus  in  the  nerve  sheaths. 

In  regard  to  the  "  reflex  convulsions  "  there  can  be  no 
doubt  that  the  great  intensity  of  the  centripetal  excitation  is 
sufficient  to  breakdown  the  intracranial  restraint,  and  through 
the  agency  of  the  centres  of  the  spinal  cord,  bring  about  a 
reflex  twitching.  It  is  however,  much  oftener  the  case  that 
"  reflex  action  "  is  heightened  and  reflex  convulsions  are  pro- 
duced, not  by  the  superior  force  of  centripetal  irritation,  but 
by  the  defective  construction  of  the  intra-cerebral  limitations. 
For  since  the  intra-cerebral  regulation  apparatus  is  based,  as 
we  have  seen,  so  largely  upon  the  conveyance  of  the  centri- 
petal irritations  to  the  brain,  it  follows  that  everything  that 
impedes  the  course  towards  their  reception  in  the  brain  must 
cause  the  irritation  to  recoil  upon  the  adjacent  centres  of  the 
spinal  marrow,  thus  producing  at  this  point  a  reflex  move- 
ment. 

The  rise  of  reflex  activity  in  a  decapitated  frog  vividly 
illustrates  this  simple  process.  Whether  certain  poisons  like 
strychnia  increase  reflex  activity  by  paralyzing  the  reflex 


164  GENERAL   PATHOLOGY. 

centres  is  an  undecided  point.  The  history  of  tetanus  proves 
that  this  may  be  accomplished  in  other  ways.  In  tetanus  the 
way  is  prepared  for  the  reflex  action  by  excessively  powerful 
centripetal  irritations,  or  there  exists  a  slight  but  prolonged 
and  uniform  irritation  proceeding  from  one  source.  This  irri- 
tation need  not  be  consciously  perceived,  i.  e.,  it  is  confined  to 
the  centres  of  the  spinal  marrow,  where  it  gradually  creates 
a  condition  of  heightened  irritability,  which  vents  itself  at 
last  in  powerful  tonic  contractions  of  all  the  muscles  of  the 
body  (compare  p.  89).  Of  similar  origin  are  the  numerous 
other  reflex  convulsions,  in  the  region  of  individual  nerves ; 
for  example,  trismus,  i.  e.,  lockjaw  in  the  region  of  the  tri- 
facial  or  fifth  verve ;  tic  convulsive  and  blepharospasmus,  in 
the  region  of  the  facial  muscles ;  torticollis  and  caput  obsti- 
pum,  in  the  region  of  the  accessorius ;  spasmodic  hiccough, 
sneezing,  yawning,  hysterics,  in  the  territory  of  the  respiratory 
muscles ;  writer's  cramp,  in  the  region  of  the  flexor  digitorum ; 
and  many  others.  Under  this  head  may  also  be  classed  what 
is  known  as  tetania,  a  spasmodic  tonic  contraction  of  the 
muscles  of  the  forearm,  in  which  a  heightened  electrical 
irritation  of  the  motor  nerves  is  perceptible.  Tetanus  and 
tetauia  are  transition  stages  of  motor  neuroses. 

Motor  Neuroses. 

We  have  already  studied  the  nature  of  "  neurosis  "  (p.  157), 
and  have  found  in  neuralgia  the  most  important  -variety  of 
sensory  neuroses.  The  motor  neuroses  are  much  more  numer- 
ous and  varied.  The  symptomatic  expression  is  much  more 
complex  than  in  neuralgia,  because  the  latter  appears  only 
subjectively,  while  all  convulsive  contractions  are  visible 
objectively,  and  display  according  to  the  individual  muscle  or 
muscles  very  changeful  pictures.  Moreover,  there  is  a  typical 
contraction  of  the  entire  muscular  system,  which  is  designed 
to  release  the  body  from  the  bent  position  assumed  intra 
uterum,  or  during  sleep,  and  to  restore  it  to  a  straighter  and 
more  natural  attitude. 

There  appears  to  be  one  particular  spot  in  the  floor  of  the 
fourth  ventricle  (convulsive  centre),  whose  only  function  con- 
sists in  this  complicated  movement.  It  appears  likewise  as  if 
there  were  an  enormous  reserve  force  of  power  waiting  to  take 
part  in  this  movement  (cerebellum  ?),  and  further  that  where 
the  restraining  power  of  the  brain  is  intact,  these  forces  are 


HYPERCINESIA — CONVULSIONS.  165 

carefully  and  judiciously  employed  in  the  desired  movements, 
but  where  the  restraint  is  impaired  there  is  an  irregular, 
extravagant,  and  exhaustive  use  of  this  pent-up  power. 

The  eclamptic  convulsion  has  been  studied  elsewhere.  In 
it  is  exhibited  the  typical  process  of  contraction  above  men- 
tioned in  its  most  unrestrained  and  exuberant  expression. 
If  our  conception  of  neuroses  did  not  include  the  idea  of 
acuteness,  eclampsia  might  be  termed  acute  neurosis.  As  it 
is,  such  a  designation  is  not  allowable,  and  we  have  only  to 
remember  that  the  typical  contraction  in  question  may  appear 
as  a  neurosis. 

Epilepsy. 

An  attack  of  convulsions  differing  in  nothing  from  the 
eclamptic  spasm  described  on  p.  86,  is  the  most  prominent 
feature  of  epilepsy.  This  attack  recurs  at  intervals  ranging 
from  a  few  hours  to  a  whole  year,  although  it  generally  occurs 
every  few  weeks.  The  mind  and  temperament  are  affected 
somewhat  according  to  the  natural  disposition  of  the  patient, 
but  on  the  whole  in  proportion  to  the  frequency  of  the  attack. 
The  memory  and  imagination  are  mainly  affected,  which 
would  imply  that  the  attacks  had  impaired  the  integrity  of 
certain  delicate  regulations  in  the  gray  substance  of  the  brain, 
which  are  formed  by  individual  mental  growth,  and  facilitate 
the  repetition  of  impressions  which  have  been  once  experi- 
enced. 

In  searching  for  the  cause  of  epilepsy  we  shall  find  that 
more  than  one-fourth  of  all  cases  are  to  be  traced  to  the 
hereditary  predisposition  which  underlies  the  "epileptic 
change  in  the  nervous  system."  And  at  least  one- half  of  all 
cases  are  chargeable  to  the  same  agency  when  we  include 
under  this  head  of  predisposing  causes  not  only  epilepsy 
proper,  but  all  serious  neuro-  and  psycho-pathic  conditions  in 
a  progenitor. 

We  are  still  in  ignorance  of  the  nature  of  the  permanent 
alteration  in  the  central  nervous  system  which  manifests 
itself  periodically  in  an  epileptic  attack.  The  conclusion  of 
one  attack  furnishes  a  starting  point  for  another,  which,  as 
soon  as  the  requisite  force  is  accumulated,  breaks  out  in  such 
parts  of  the  central  nervous  system  as  are  in  possession  of  the 
abnormal  condition.  Hence  we  are  inclined  to  view  this  as  a 
condition  of  abnormal  excitability,  which,  induced  primarily 
by  some  local  irritation,  becomes  finally  domesticated  and 


166  GENERAL   PATHOLOGY. 

independent  of  the  exciting  cause,  and  constitutes  an  indepen- 
dent, transmissible  disease. 

This  view  is  favored  by  the  results  of  experiments  on  ani- 
mals as  regards  the  primary  origin  of  epilepsy.  In  guinea 
pigs,  namely,  the  "  epileptic  change  "  is  brought  about,  and 
the  first  epileptic  attacks  occur  in  from  four  to  six  weeks  after 
lesions  of  the  spinal  marrow,  medulla  oblongata,  crura  cerebri, 
or  corpora  quadrigemina,  as  well  as  after  section  of  one  or 
both  sciatic  nerves.  We  know,  furthermore,  that  epilepsy 
thus  produced  in  guinea-pigs  is  often  transmitted  to  their 
young. 

In  very  many  instances  medical  observation  is  able  to  refer 
the  origin  of  the  epileptic  change  to  a  local  irritation  of 
the  nervous  system  ;  to  external  violence,  especially  upon  the 
skull,  to  wounds,  scars  and  tumors  on  the  peripheral  nerves, 
to  tumors  of  the  female  genital  apparatus,  to  intracranial 
exostoses,  to  the  pressure  of  an  abnormally  protruding  dens 
epistrophei  upon  the  anterior  surface  of  the  medulla  oblon- 
gata, etc. 

Pursuing  this  line  of  investigation  and  experiment,  we  are 
led  to  seek  the  essential  cause  of  this  malady  in  the  abnormal 
excitation  of  the  reflex  centres  of  the  spinal  cord  and  pons 
varolii.  Acquired  or  transmitted  defects  of  the  brain,  by 
which  it  is  rendered  incapable  of  exerting  normal  restraint 
upon  the  activity  of  these  centres,  might  be  adduced  in  support 
of  this  theory — which,  however,  is  far  from  being  established. 
We  must  not  forget  that  the  epileptic  fit  is  invariably  asso- 
ciated with  a  suspension  of  consciousness  and  a  sudden  anaemia 
of  the  cerebrum.  No  one  will  deny  that  these  two  features 
are  intimately  associated  with  the  outbreak  of  convulsions. 
The  advocates  of  the  irritation  theory  say  that  the  irritation 
of  the  convulsive  centre,  and  the  simultaneous  excitation  of 
the  neighboring  vasomotor  centre,  occasions  a  contraction  of 
the  cerebral  blood  vessels,  resulting  in  the  phenomena  above 
mentioned.  Any  one  who  has  had  occasion  to  witness  the 
entire  course  of  an  epileptic  attack,  although  he  may  concede 
the  possibility  of  such  a  connection,  will  not  forget  that  the 
pallor  and  the  unconsciousness  precede  the  convulsions  by  two 
to  ten  seconds,  and  will,  in  consequence,  be  apt  to  attribute 
the  excessive  action  of  the  reflex  centres  to  a  lack  of  restraint 
on  the  part  of  the  ansemic  brain.  The  breaking  down  of  the 
cerebral  restraint,  considered  as  a  variety  of  brain  exhaustion, 


HYPERCINESIA — CONVULSIONS.  167 

would  also  be  a  cumulative  force,  which,  when  the  maximum 
was  reached,  would  lead  to  an  acute  prostration  of  conscious- 
ness and  a  simultaneous  discharge  of  motor  force. 

I  say  "  would  be  "  and  "  would  lead,"  for  I  am  unwilling  to 
overthrow  an  hypothesis.  I  can,  however,  plead  as  an  excuse 
the  many  well  established  cases  where  epilepsy  has  resulted 
from  toxic  irritation  of  the  brain,  as  in  drunkenness,  or  from 
functional  over  excitement,  as  in  fright  or  insanity.  The 
manifold  fluctuations  in  the  quantity  of  blood  contained  in  the 
cerebral  blood  vessels  can  very  readily  pass  into  the  incipient 
stages  of  cerebral  neurosis,  where  they  constitute  the  leading 
element.  We  shall  some  day,  perhaps,  learn  to  discriminate 
between  reflex  and  cerebral  epilepsy.  The  fact  that  the 
etiological  characteristics  of  both  are  interchangeable  admits 
a  large  number  of  intermediate  varieties. 
Catalepsy  and  Hypnotism. 

Closely  allied  to  epilepsy  is  catalepsy,  which  is  distinguished 
by  paroxysmal  attacks  of  cataleptic  convulsions,  such  as 
described  on  page  162.  Here  also  we  find  the  abnormal 
activity  of  the  convulsive  centre  associated  with  complete  or 
partial  loss  of  consciousness.  That  brain  exhaustion  is 
primarily  concerned  here  is  proved  by  the  recent  careful  in- 
vestigations into  the  nature  of  hypnotism,  commonly  called 
somnambulism.  In  these  experiments  catalepsy  is  produced 
artificially.  The  individual  chosen  for  the  purpose  is  made  to 
gaze  steadily  at  some  shining  object — the  head  of  a  scarf-pin, 
let  us  suppose — which  is  held  motionless  a  few  inches  away 
from  the  eyes.  This  fixed  scrutiny  in  a  short  time  exhausts 
the  brain  to  such  a  degree  that  a  mesmeric  sleep  ensues. 
While  in  this  condition  the  body  is  insensible  to  bodily  paiu, 
to  pricks,  burns,  etc. ;  conscious  movements  are  replaced  by 
the  cataleptic  state.  The  mind  can  only  be  reached  by  the 
higher  organs  of  sense.  The  responses  which  can  be  evoked 
from  a  hypnotized  person  by  addressing  them  distinctly,  dis- 
playing certain  objects,  and  conveying  impressions  of  smell 
and  taste,  are  not  clear  and  conscious  utterances,  but  merely  a 
mechanical  reproduction  of  familiar  perceptive  processes. 
Charcot  has  very  aptly  called  them  psychical  automata. 
Chorea. 

A  weakened  brain  and  an  incapacity  to  control  the  move- 
ments of  the  motor  centres  of  the  spinal  cord  are  the  pre- 


168  GENERAL   PATHOLOGY. 

requisites  for  choreic  spasms.  Under  the  name  of  chorea 
minor  it  appears  before  puberty  as  a  transient  neurosis ;  as 
chorea  major  it  constitutes  one  of  the  most  dangerous  and 
severe  varieties  of  anatomical  lesions  of  the  brain. 

In  chorea  minor,  the  weakening  of  the  brain  is  relative, 
inasmuch  as  this  organ  has  not  kept  pace  with  the  rapid 
development  of  the  genital  apparatus  and  the  many  excita- 
tions reaching  it  from  that  source.  In  chorea  major,  the 
impaired  brain  activity  is  absolute  and  degenerates  into  com- 
plete paralysis.  The  spasms  in  chorea  are  twitchings  of  in- 
dividual groups  of  muscles,  attacking  first  one  point,  then 
another,  with  lightning-like  rapidity.  The  arm  is  bent,  the 
hand  undergoes  first  pronation,  then  supination,  the  fingers 
are  spread  out,  the  shoulder  raised,  the  head  is  thrown  back, 
the  eyes  distorted,  the  tongue  projected  and  immediately 
drawn  in,  the  teeth  are  ground  together,  the  knee  is  suddenly 
raised,  so  that  the  sufferer  is  thrown  to  the  ground.  The 
patient  is  unable  to  feed  himself,  as  it  is  impossible  to  control 
the  motions  of  the  hand  and  arm.  In  chorea  major,  the 
movements  are  even  more  powerful,  amounting  to  twistings 
and  contortions  of  the  entire  body. 

The  movements  are  entirely  beyond  the  control  of  the 
patient.  He  feels,  on  the  contrary,  that  even  voluntary 
movements  must  be  carefully  guarded,  lest  their  exercise 
should  give  free  rein  to  those  which  are  uncontrollable.  His 
mind  is  weary  and  confused,  and  memory,  appetite  and  sleep 
are  disturbed. 

HYPOCINESIA,  PARALYSIS. 

More  simple  in  appearance  and  origin  than  the  arbitrary 
contractions  of  the  muscles,  is  their  more  or  less  pronounced 
inability  to  respond  to  the  will,  as  seen  in  paralysis  or  paresis 
(partial  paralysis)  of  the  muscles.  Everything  which  influences 
the  musculo-motor  apparatus  to  such  a  degree  as  to  cause  an 
impairment  of  function  is  expressed  symptomatically  as  a 
paralysis  of  the  muscle  or  muscles  in  question.  The  result 
is  the  same  whether  the  point  of  attack  be  in  the  very  first 
beginnings  of  the  apparatus — in  the  laboratories  of  the  will 
situated  in  the  cerebral  cortex;  or  in  the  intra-muscular  nerve- 
terminations,  or  the  muscular  substance  itself.  These  lesions 
are  of  the  most  diverse  nature.  In  order  to  limit  their  terri- 
tory, it  has  been  customary  to  make  a  distinction  between  the 


HYPOCINESIA,    PARALYSIS.  169 

strictly-speaking  nervous  paralysis,  and  the  inaction  of  the 
passive  organs  of  motion,  the  bones  and  joints,  as  well  as 
the  disturbances  of  purely  muscular  function.  Although  this 
division,  as  we  have  repeatedly  remarked,  is  incorrect  in  view 
of  the  strict  continuity  between  these  parts  and  the  nervous 
system,  we  will  adopt  it  for  the  sake  of  convenience,  and 
only  speak  of  paralysis  proper  in  connection  with  lesions  of 
the  nervous  system. 

(tt)    PERIPHERAL   PARALYSIS. 

Whether,  independent  of  the  well  known  effect  of  the 
American  Indian  arrow  poison,  woorara,  upon  the  intra- 
muscular nerve  terminations,  there  is  still  another  form  of 
paralysis  which  is  confined  exclusively  to  this  portion  of  the 
musculo-motor  apparatus,  remains  a  doubtful  question.  On 
the  other  hand,  the  entire  peripheral  course  of  the  motor 
nerve  fibres,  from  the  brain  to  their  entrance  in  the  muscles, 
is  exposed  to  countless  traumatic  lesions.  Such  lesions  are : 
contusions  and  lacerations  from  gunshot  and  sabre  wounds, 
from  fractures  and  dislocations,  compression  from  inflamma- 
tory new  formations  and  tumors,  leading  to  complete  or  partial 
destruction  of  nerve  fibres  and  to  corresponding  paralysis  of 
the  attendant  muscles. 

Experiment  has  shown  that  motor  fibres  offer  an  astonish- 
ingly slight  resistance  towards  all  mechanical  injuries.  A 
pressure  of  eighteen  or  twenty  inches  of  quicksilver,  for  a 
space  of  fifteen  minutes,  is  sufficient  to  interrupt  motor  impulses 
for  a  considerable  period  of  time.  Section  of  a  nerve  is  fol- 
lowed by  instantaneous  and  total  paralysis  of  the  muscles 
concerned.  If  reunion  of  the  two  sections  is  impossible,  the 
paralysis  is  permanent,  but  if  they  are  successfully  approxi- 
mated, it  disappears  gradually  but  completely.  The  ana- 
tomico-physiological  changes  which  the  peripheral  nerve 
endings  and  their  muscles  undergo  at  such  a  time  are  so 
typical  and  so  valuable  in  forming  a  prognosis  that  they  are 
worthy  of  especial  mention. 

First,  as  regards  anatomical  changes.  We  distinguish  (1) 
a  series  of  degenerate  processes,  occasioned  by  section  of  the 
nerves ;  (2)  a  series  of  regenerate  processes,  which  facilitate 
the  union  of  the  sections,  check  further  degeneration,  and 
repair  the  injuries  already  received. 

Degeneration  sets  in  at  once  after  section.     A  portion  of 


170  GENERAL  PATHOLOGY. 

the  nerve  medulla  exudes  from  the  cut  ends  of  the  nerve  fibres, 
and  the  tubular  membrane  is  cleft  apart  some  distance  along 
its  course.  In  this  cleavage  appear  cylindrical  flakes  and 
round  drops,  to  which  are  added,  after  the  seventh  day,  ordi- 
nary fat  granules,  which  congregate  in  spots,  forming  a  sort 
of  compound  granule-cell.  All  the  products  are  reabsorbed 
by  degrees,  leaving  only  a  narrow,  pale,  ligamentous  substance 
behind,  consisting  of  the  axis  cylinder  and  Schwann's  sheath 
(tubular  membrane).  In  this  manner  the  fibre  is  preserved 
for  weeks  and  months,  waiting  to  be  restored  by  innervation. 

The  paralyzed  muscles  remain  intact  somewhat  longer  than 
the  motor  nerve  fibres.  It  is  only  after  the  expiration  of 
some  weeks  that  there  is  a  decided  atrophy  of  the  individual 
muscular  fibres,  with  obliteration  of  the  transverse  striae. 
This  atrophy,  betraying  itself  macroscopically  in  a  corres- 
ponding emaciation  of  the  belly  of  the  muscle,  leads  at  last 
to  the  degeneration  and  total  loss  of  contractility. 

Side  by  side  with  these  purely  degenerative  changes,  and 
following  like  them  immediately  upon  the  solution  of  con- 
tinuity, are  restorative  processes  which  are  calculated  to 
regenerate  the  disturbed  nerve-paths  and  the  muscles  which 
have  been  threatened  or  already  injured  by  atrophy. 

A  young,  soft  connective  tissue,  well  provided  with  cells, 
is  deposited  in  the  interstices  between  the  nerve-filaments. 
Conspicuous  among  the  cells  are  certain  large,  spindle- 
shaped  ones,  whose  polar  offshoots  follow  the  longitudinal 
axis  of  the  severed  nerve,  thus  effecting  a  protoplasmic  union 
of  the  detached  and  sundered  fibres.  This  establishes  a 
bridge  between  the  central  and  peripheral  trunk,  which  in 
process  of  time  is  converted  by  corresponding  development 
into  a  genuine  nerve-fibre.  This  favorable  termination  can, 
of  course,  only  be  expected  when  the  gap  between  the  central 
and  peripheral  nerve  trunks  is  not  too  great.  If,  however,  it 
is  once  completed,  all  abnormalities  of  the  nerves  vanish  by 
degrees,  and  the  paralyzed  muscle  regains  its  former  volume 
and  firmness,  together  with  its  full  contractility.  The  manner 
in  which  this  restitution  of  the  muscular  substance  is  brought 
about  depends  upon  the  degree  of  the  previous  degeneration. 
The  muscular  substance  appears  capable  of  restoration  as  long 
as  the  striation  is  preserved.  When  that  is  lost,  and  the 
muscular  substance  disintegrates  into  certain  homogeneous, 
shiny,  waxy  flakes,  a  complete  reconstruction  of  the  contractile 


HYPOCINESIA,   PARALYSIS.  171 

cylinders  becomes  necessary.  The  material  for  this  is 
doubtless  furnished  by  the  non-degenerated  and  rapidly 
proliferating  muscle  corpuscles. 

Complete  degeneration  of  the  paralyzed  muscle  is  the 
inevitable  result  where  there  is  a  failure  to  re-establish  con- 
tinuity between  the  central  and  peripheral  nerve-ends.  It  is 
associated  with  vasomotor  paralysis  produced  by  section  of 
the  vasomotor  nerve-paths.  The  immediate  consequence  of 
this  vasomotor  paralysis  is  an  arterial  hypersemia,  which, 
however,  after  the  prolonged  dilatation  and  ultimate  relaxa- 
tion of  the  vascular  walls,  takes  on  a  more  lasting  character, 
and  like  the  venous  hypersemias,  furnishes  the  basis  for  a 
slowly  increasing  proliferation  of  connective  tissue.  The 
atrophied  muscular  fibres  are  entirely  destroyed  in  the  pro- 
gress of  this  growth,  and  the  bellies  of  the  muscles  are  trans- 
formed into  a  tough,  ligamentous,  fibrous  mass,  whose  other- 
wise homogeneous  surface  is  varied  by  occasional  striae  of 
adipose  tissue  and  rows  of  fat  cells. 

So  much  for  the  anatomical  changes  which  we  must  expect 
to  meet  in  all  peripheral  paralysis  of  the  nerves  and  muscles. 
Their  main  features  have  long  been  known.  But  modern 
science  points  out  certain  physiological  characteristics,  by 
means  of  which  we  are  able  to  recognize  with  almost  absolute 
certainty  a  peripheral  paralysis,  and  discriminate  between  it 
and  most  paralyses  of  central  origin.  I  allude  to  the  so-called 
"  reaction  of  degeneration  "  in  the  paralyzed  parts,  i.  e.,  to  the 
effect  produced  upon  them  by  electric  currents,  which  is  at 
times  very  striking.  For  either  afaradic  or  galvanic  current, 
applied  to  the  nerves  of  the  paralyzed  muscle,  produces  a 
gradual  fall  and  a  subsequent  rise  of  excitability,  which  is 
exactly  proportioned  to  the  processes  of  degeneration  and 
restoration  described  above.  But  in  applying  electricity  to  the 
paralyzed  muscle  itself,  the  same  effect  can  only  be  produced 
by  the  irritation  of  the  induced  current  of  short  duration. 
On  the  other  hand,  galvanism  produces  in  the  second  week, 
after  the  occurrence  of  the  paralysis,  a  very  marked  rise  of 
excitability,  which  continues  to  augment,  during  the  next 
week,  and  disappears  only  gradually,  whether  a  cure  be 
effected  or  the  paralysis  become  permanent.  Electro-muscular 
contractility  does  not  take  place  suddenly,  as  in  the  healthy 
muscle,  but  slowly,  although  vigorously,  and  with  a  pro- 
nounced tendency  towards  prolonged  muscular  tonus.  The 


172  GENERAL   PATHOLOGY. 

law  of  contraction  undergoes  here  a  quantitative  alteration. 
Strong  contractions  are  not  produced  by  the  cathodic  (+), 
but  by  the  anodic  ( — )  closure,  while  on  the  other  hand,  the 
weak  and  very  soon  extinguished  opening  contraction  is 
greater  with  the  cathode  than  the  anode. 

It  can  scarcely  be  doubted  that  this  phenomenon  proceeds 
from  the  determined  opposition  of  the  so-called  idio-muscular 
contractility  to  the  neuro-muscular.  Further  discoveries  must 
show  us  the  relation  of  this  to  the  incipient  degeneration  of 
the  muscle. 

(6)   SPINAL    PARALYSIS. 

When  the  spinal  marrow  is  subjected  to  any  of  the  more 
extended  pathologico-anatomical  changes,  which  involve  the 
entire  transverse  section,  the  paralysis  thereby  induced 
involves  all  the  motor  nerves  arising  below  this  point.  It  is 
always  on  both  sides  of  the  body  (paraplegic),  ascending,  and 
complicated  with  paralysis  of  the  bladder,  because  the  nerves 
of  the  latter  arise  from  the  lowest  section  of  the  spinal  marrow. 
The  participation  of  the  symmetrical  muscles  of  the  lower 
extremities,  trunk  and  upper  extremities  is  regulated  by  the 
seat  of  the  disease,  according  as  this  is  located  in  the  lumbar, 
thoracic,  or  cervical  regions  of  the  spinal  cord.  Sensibility  is 
destroyed  in  the  same  proportion,  although  experience  has 
shown  that  sensation  is  by  no  means  as  easily  interrupted  as 
motion.  One  peculiarity  of  spinal  paralysis  is  the  sensation 
as  of  a  girdle  or  belt  fastened  around  the  body.  This 
"feeling  of  constriction"  is  associated  with  abnormal  sensa- 
tions, formications,  etc.,  in  the  feet. 

Reflex  action  below  the  seat  of  the  injury  is  at  first  height- 
ened, afterwards  also  impaired. 

A  more  complicated  variety  of  spinal  paralysis  is  found  in 
those  anatomical  lesions  which  produce  a  partial  but  never 
complete  suspension  of  function  at  many  different  points  of 
the  spinal  cord.  Most  cases  of  so-called  gray  degeneration  of 
the  brain  and  spinal  cord  belong  to  this  class.  As  the  name 
indicates,  the  white  substance  becomes  discolored,  and  presents 
a  reddish-gray  aspect,  resembling  outwardly  the  ordinary  gray 
matter  of  the  brain.  The  diseased  part  exhibits  at  the  same 
time  a  considerable  decrease  in  volume.  The  true  action  of 
this  process  is  as  yet  unknown.  The  name  of  "  gray  degener- 
ation "  is  well  chosen,  inasmuch  as  the  gray  coloring  is  mainly 


HYPOCINESIA,    PARALYSIS.  173 

determined  by  the  loss  of  the  white,  shining  and  oily  myeline 
of  the  medulla  of  the  nerve  fibres.  The  name,  therefore, 
emphasizes  that  change  which  without  doubt  furnishes  the 
immediate  cause  of  the  disturbed  function.  So  soon  as  the 
nervous  conduction  loses  the  isolation,  which  is  effected  solely 
by  the  stability  of  an  intact  medullary  sheath,  the  clearness 
and  independence  both  of  simultaneous  sensation  and  simulta- 
neous motor  impulse  becomes  imperiled,  if  not  abolished. 
While  there  is,  on  the  one  hand,  a  constant  increase  and 
fusion  of  the  sensations  appertaining  to  the  sensibility  of  the 
skin,  so  that  conscious  sensation  is  entirely  overcome  or  re- 
placed by  a  chaos  of  parsesthesias,  we  see,  on  the  other  hand,  a 
remarkable  separation  of  the  combined  motor  phenomena  into 
their  elements — the  so-called  ataxia  motoria.  A  healthy  per- 
son executes  voluntary  movements  by  a  single  impulse,  because 
of  the  well  drilled  co-operation  of  individual  contractions  in 
the  muscles  concerned.  The  axis  cylinders  which  guide  the 
motor  impulses  are  probably  lodged  in  close  proximity  to 
each  other  in  the  medullary  substance  of  the  brain,  and  even 
more  in  that  of  the  spinal  cord  ;  but,  as  long  as  they  are  prop- 
erly enveloped  in  myeline,  the  isolated  condition  of  the 
attendant  motor  impulses  is  assured.  In  the  absence  of  the 
myeline  stratum,  an  effect,  to  be  produced  at  all,  must  be  the 
result  of  individual  action  on  the  part  of  each  motor  impulse, 
while  the  co-ordinate  motion  resolves  itself  into  a  succession  of 
heterologous,  and,  in  part,  antagonistic  movements.  The 
simplest  instance  of  a  loss  of  co-ordinate  power  is  seen  in 
the  trembling  palsy  (Intentions-Zittern),  which  appears  char- 
acteristically in  those  suffering  from  repeated  scleroses  of  the 
brain  and  spinal  cord.  In  a  reclining  position  this  is  hardly 
perceptible,  but  no  sooner  does  the  patient  attempt  to  walk, 
stand,  or  grasp  anything,  than  he  is  overtaken  by  a  trembling 
and  snaking  which  is  strong  in  proportion  to  the  energy  of  the 
intended  action.  Similar  appearances  accompany  movements 
of  the  tongue,  lips  and  eyeballs. 

Real  ataxia,  which  presents  an  especially  typical  phase  in 
tabes  dorsalis,  does  not  confine  itself  to  mere  trembling  and 
shaking  of  the  limbs.  The  movement  of  the  limbs  in  walk- 
ing is  jerky,  irregular  and  uncertain,  the  abrupt  extension  of 
the  knee  brings  the  foot  down  solidly  upon  the  ground.  All 
the  movements  are  zigzag,  and  must  be  controlled  by  the  eye, 
otherwise,  on  account  of  the  lack  of  the  sense  of  position,  the 


174  GENERAL   PATHOLOGY. 

aim  is  overreached.    Even  in  attempting  to  stand  with  closed 
eyes,  the  patient  will  stagger  and  fall. 

Besides  these  unmistakable  lesions  of  the  spinal  cord  and 
its  disturbed  function,  there  is  an  extensive  group  of  so-called 
reflex  paralyses,  which  are  the  result  of  peripheral  irritation. 
On  this  account,  partly,  and  partly  on  account  of  the  double 
nature  of  their  appearance,  we  are  led  to  seek  the  origin  of 
these  paralyses  in  the  spinal  marrow.  They  are  most  frequent 
after  severe  disorders  of  the  abdominal  organ,  after  dysentery 
and  diseases  of  the  bladder  and  uterus,  painful  delivery,  etc., 
and  are  of  a  progressive  and  often  incurable  character. 
They  resemble  the  above-described  reflex  convulsions  to  a 
certain  degree,  the  former  being  the  result  of  an  abnormal 
irritation  of  the  reflex  centres,  the  latter  of  an  over-excitation 
and  complete  exhaustion  of  the  same.  A  tangible  basis  for 
all  these  changes  is  greatly  to  be  desired.  In  some  cases  of 
reflex  convulsions,  and  also  reflex  paralyses,  there  have  been 
found  distinct  traces  of  inflammatory  hypersemia,  or  infiltra- 
tion, and  even  hemorrhage  and  softening  in  the  spinal  cord 
itself,  or  in  the  outposts  of  the  central  gray  matter  in  the 
intervertebral  or  basal  ganglia.  An  ascending  neuritis  has 
even  been  remarked,  affecting  finally  the  entire  reflex  system. 
All  these  instances,  however,  are  of  a  casual  nature,  although 
no  case  of  tic  douloureaux,  of  convulsions,  or  reflex  paral- 
ysis should  be  allowed  to  leave  the  post-mortem  table  without 
a  careful  anatomical  and  histological  scrutiny  of  the  involved 
centres. 

(c)    CEREBRAL   PARALYSIS. 

Cerebral  paralyses  must  be  divided  into  those  which  are 
produced  by  a  palpable  lesion  of  the  main  channels  of  the 
will  power,  and  into  those  which  are  properly  central,  having 
their  seat  in  the  part  impressed  by  the  will,  the  cerebral 
cortex.  These  cerebral  paralyses  (due  most  frequently  to 
hemorrhages,  softenings,  inflammatory  and  non-inflammatory 
new  formations)  are,  as  a  rule,  hemiplegic,  i.  e.,  they  affect 
only  one  side  of  the  body,  and  that  the  one  opposite  the 
injured  hemisphere.  The  upper  extremities  are  usually  most 
severely  affected,  then  the  face,  which  on  the  paralyzed  side 
is  smooth  and  flabby,  the  tip  of  the  tongue  also  when  pro- 
truded inclines  towards  the  diseased  side. 

About  purely  central  paralyses  there  is  little  to  be  said. 


PSYCHICAL   IRRITATION   AND   PARALYSIS.  175 

The  mind  is  characteristically  affected  by  a  simple  or  ex- 
citable weakness  of  the  combined  powers  of  sensation,  imagina- 
tion and  will,  which  is  liable  to  end  in  total  imbecility 
(progressive  paralysis,  paralytic  imbecility).  Besides  this  we 
find  total  and  semi-paralyses  of  widely  divergent  motor  paths, 
especially  of  the  muscles  employed  in  phonation.  They  de- 
velop rapidly  up  to  a  certain  point,  after  which  they  increase 
slowly,  remain  stationary,  or  even  retrograde.  In  many  of 
them  the  anatomical'  position  of  the  disease  may  with  reason- 
able certainty  be  located  at  a  particular  point  in  the  cerebral 
cortex,  since  experimental  pathology  has  lately  pointed  out 
the  localities  where  the  will  power  appears  to  concentrate  in 
order  to  execute  certain  co-ordinate  movements. 

The  anatomical  changes  which  lead  to  central  paralyses  are 
due  chiefly  to  chronic  inflammations,  with  connective  tissue 
proliferation  and  subsequent  contraction.  Although  irrepar- 
able in  themselves,  the  disturbances  thus  caused  are  up  to  a 
certain  point  capable  of  equalization,  owing  to  the  superior 
capability  of  the  brain  for  the  performance  of  vicarious 
functions.  Beyond  this  point  the  extended  nature  of  the 
disease  makes  equalization  impossible  and  the  paralysis  be- 
comes permanent. 

PSYCHICAL  IRRITATION  AND  PARALYSIS. 

There  are  certain  pathological  changes  which  attack  the 
whole  or  a  part  of  the  cerebral  cortex.  Although  their  post- 
mortem appearance  is  only  that  of  a  protracted  hypersemia 
and  its  results,  we  need  not  be  surprised  to  meet  pathological 
symptoms  which  resemble  those  of  a  mind  which,  though 
over-excited,  or  it  may  be  totally  exhausted,  is  still  normal. 
This  resemblance  is  sometimes  so  close  that  we  are  led  to 
question  whether  it  will  ever  be  possible  in  every  instance 
to  discriminate  accurately  between  the  irresponsible  demeanor 
of  an  unscrupulous  person,  and  the  same  actions  in  a  lunatic. 
The  judges  in  such  a  predicament  are  constrained  to  consult 
the  physician.  The  latter,  if  sufficiently  authorized  by  the 
facts,  need  not  pronounce  the  condition  one  of  mental  health, 
but  one  of  mental  derangement.  The  chief  criterion  of  the 
psychical  anomaly  presents  itself  as  follows  : — 

A  sane  individual  displays  in  his  perceptions  and  emotions, 
as  well  as  in  his  thoughts,  words  and  deeds,  a  well  pro- 
portioned relation  to  preliminary  circumstances  and  con- 


176  GENERAL  PATHOLOGY. 

ditions.  The  tranquil  course  of  this  mental  activity,  from 
the  external  impulse  through  all  the  stages  of  psychical  life 
until  it  finds  motory  expression,  is  interfered  with  by  the 
anatomical  change  in  the  cerebral  cortex,  which  either  in- 
creases its  irritability  in  the  most  surprising  manner,  or 
paralyzes  it.  The  symptoms  of  this  irritation  are  psychical. 
They  associate  themselves  with  the  emotional  and  imaginative 
life,  sometimes  in  harmony,  sometimes  at  variance  with  the 
will,  but  differ  from  the  physiological  processes  in  that  they 
are  executed  under  the  pressure  of  an  irresistible  inner 
impulse,  "  without  sufficient  psychical  motive."  The  source 
of  this  compulsion  is  the  diseased  condition  of  the  cerebral 
cortex. 

Much  stress  has  been  laid  upon  the  "  element  of  excess"  in 
psycho-pathological  symptoms.  But  when  we  consider  what 
an  enormous  amount  of  power  the  physiological  brain  is  able 
to  exert,  we  soon  come  to  the  conclusion  that  the  psycho- 
pathological  appearances  appear  excessive  only  because  they 
are  entirely  disproportionate  to  the  preliminary  causes,  or  else 
have  no  apparent  cause  at  all.  Indeed,  the  "  illogical,  forced, 
compulsory "  element  in  psychological  processes  is  the  only 
really  fundamental  feature  by  which  they  can  be  discrimi- 
nated. 

The  typical  groups  of  symptoms  are  quite  varied,  although 
three  principal  groups  may  be  mentioned,  (1)  those  of  mod- 
erate irritation  ;  (2)  those  of  stronger  psychical  irritation  ; 
(3)  those  of  psychical  paralysis. 

Moderate  psychical  irritation  exists  only  as  long  as  the 
patient  is  able  to  give  vent  to  his  inner  agitation  in  a  cor- 
responding degree  of  expression  (hyperthymia,  hedonia, 
mania).  The  mind  is  full  of  images,  following  each  other 
without  logical  sequence  (hallucinations).  The  images  are 
expressed  in  words,  the  words  in  deeds.  In  this  excitation 
the  first  symptom  is  an  aimless  rushing  hither  and  thither  and 
purposeless  activity  ;  the  next  is  continuous  chattering,  sing- 
ing, dancing,  boasting,  and  unseemly  actions  (nymphomania), 
until  the  crisis  is  reached  in  wild  shrieks  and  cries,  blind 
violence  and  destructiveness,  and  powerful  and  astonishing  ex- 
hibitions of  muscular  strength  (frenzy).  All  this  is  in  strong 
contrast  to  the  trivial  nature  of  the  external  irritation  which 
appears  to  have  occasioned  such  abnormal  effects.  On  the 
other  hand,  the  perception  of  the  most  insignificant  objects  is 


PSYCHICAL  IRRITATION   AND   PARALYSIS.  177 

wonderfully  heightened.  The  patient  sees  and  hears  every- 
thing, and  appears  exceptionally  bright  and  happy.  The 
easy  transition  from  ideas  to  words,  from  desires  to  deeds, 
causes  at  first  an  intensified  enjoyment  of  life,  such  as  only 
those  can  appreciate  who  have  themselves  felt  the  inspiring 
and  energizing  power  of  healthful  activity. 

It  may  to  many  appear  paradoxical  to  class  frenzy,  which 
is  assuredly  not  mild  in  character,  with  the  moderate  psychical 
irritations.  But  although  it  may  appear  to  the  uninitiated  as 
the  "mad  raving"  of  a  lunatic,  the  alienist  is  well  aware  of 
its  inoffensive  nature. 

We  are  authorized  to  assume  the  presence  of  increased 
psychical  irritation  whenever  the  patient  is  no  longer  in  a 
condition  to  convert  the  impressions  which  throng  in  upon 
him  into  action ;  when,  realizing  his  powerlessness,  he  relapses 
into  deep  spiritual  depression  (melancholia).  The  images 
which  pass  through  his  mind  are  feeble  and  fluctuating.  His 
paucity  of  ideas  is  painfully  apparent  even  to  himself.  Fresh 
irritations,  which  reach  him  from  without,  leave  no  trace  upon 
his  stupefied  senses.  Every  hope  and  wish,  every  desire  and 
ambition,  seem  paralyzed.  In  connection  with  the  most  ad- 
vanced stages  of  psychical  trouble  there  is  often  an  absolute 
lack  of  energy,  a  stupor  (mania  attonita).  In  other  instances, 
there  are  detached  and  violent  explosions,  with  a  total  dis- 
regard for  the  safety  of  the  patient  himself  or  those  about 
him. 

If  a  person  suffering  from  melancholia  is  still  able  to  think, 
his  mind  is  filled  with  the  most  depressing  images.  He  broods 
over  his  own  unworthiuess,  and  his  self-accusations  often  lead 
to  rejection  of  food  and  attempts  at  suicide.  He  becomes  pos- 
sessed with  the  idea  that  he  is  pursued,  and  the  overclouded 
mind  pictures  to  itself  the  most  frightful  dangers  and  troubles 
which  are  about  to  overtake  him.  The  dread  ripens  finally 
into  a  fixed  conviction,  and  the  so-called  "illusions"  become 
a  deeply-rooted  and  ruling  power  in  the  otherwise  deserted 
world  of  thought. 

We  cannot  leave  this  strange — I  might  say  specific — pro- 
duct of  psychical  disturbance,  the  development  of  hallucina- 
tion, without  further  comment.  It  shows  how  even  the  in- 
tellectual life  may  fall  a  prey  to  genuine  neurosis,  and  in  the 
same  manner  as  the  general  run  of  neuroses  already  indicated 
on  pp.  156, 157.  Hallucination  is  a  group  of  impressions,  which 


178  GENERAL  PATHOLOGY. 

is  accompanied  by  especially  strong  emotions,  and  in  a  measure, 
is  caused  by  them,  and  on  this  account  is  longer  retained 
i.  e.,  is  more  frequently  repeated.  Now  in  proportion  as  the 
desire  is  repeated  on  the  part  of  the  individual  to  realize  the 
visionary  idea,  or  he  is  fearful  and  anxious  lest  it  come  true, 
the  brain  learns  to  adapt  itself  to  the  diseased  exercise  of  these 
impressions,  so  that  they  recur  finally  with  the  greatest  ease 
and  almost  without  external  incitation.  The  excited  brain 
may  be  compared  to  soil  in  which  the  delusion  has  taken  firm 
root,  and  become  fixed  like  an  arrow  in  the  flesh,  lacking 
organic  connection  with  the  other  reasoning  processes  of  the 
person,  an  elem'ent  as  foreign  to  the  individuality  as  if  belong- 
ing to  some  one  else.  Yet,  if  we  set  aside  all  the  dreadful 
adjuncts  which  our  fancy  applies  to  lunacy,  we  find  nothing 
but  a  simple  neurosis,  and  that  a  delusion  is  nearest  in  kin 
to  neuralgia. 

The  groups  of  symptoms  already  considered  presuppose  an 
anatomical  condition  of  the  brain  in  which  the  exercise  of  its 
functions  is  advanced  or  hindered,  but  never  completely 
arrested.  An  effectual  arrestation  of  the  activity  of  the 
cerebral  cortex,  a  psychical  paralysis,  only  occurs  after  certain 
changes  have  set  in,  which,  though  slight  in  themselves,  are 
diffuse,  insidious  and  irrevocable,  and  result  in  atrophy  of  the 
cerebral  centre.  They  develop  equally  in  the  brain  of  an 
acute  psychosis  or  of  other  cerebral  disturbances,  or  they 
appear  in  conjunction  with  a  persistent  or  often  re-appearing 
hypersemia,  as  in  alcoholism. 

What  is  commonly  called  weak  mindedness  or  idiocy  is  a 
deterioration  and  ultimate  deadening  of  energy  in  all  the  depart- 
ments of  intellectual  life,  and  forms  the  cardinal  symptom  of 
psychical  paralysis.  Memory  usually  suffers  first.  This  pro- 
duces breaks  in  the  chain  of  impressions,  and  destroys  the 
logical  sequence  of  the  reasoning  process.  The  warmth  and 
tenderness  of  the  emotional  nature  is  lost ;  a  repellant  indif- 
ference in  morals  and  aesthetics  takes  their  place.  Desires 
and  ambitions,  however  temperate  they  may  have  been,  being 
no  longer  controlled  by  the  will,  force  themselves  to  the  sur- 
face of  the  impoverished  mind  and  produce  vacillations  of  the 
most  ludicrous  and  disconnected  sort.  If  a  hallucination  has 
once  been  cherished,  it  is  apt  to  survive  for  a  time  the  general 
wreck,  although  it  is  no  longer  able  to  greatly  transport  or 
excite  the  person. 


NEURO-VEGETAL   DISTURBANCES.  179 

NEURO-VEGETAL  DISTURBANCES. 

It  is,  par  excellence,  an  animal  regulation  that  even  the  nutri- 
tive processes  are  in  a  certain  degree  subject  to  the  authority 
of  the  nervous  system.  Assimilation  is,  indeed,  one  of  the 
fundamental  conditions  of  living  matter.  It  can,  indepen- 
dent of  all  nervous  authority,  accomplish  much  that  is  grand 
and  beautiful,  as  the  vegetable  kingdom  constantly  teaches. 
There  are  even  diseased  conditions  in  the  organism,  which  are 
nothing  more  than  an  uncontrolled  assimilation  of  fresh  vitality 
by  that  already  existing.  This  assimilation  which  rejects  the 
regulation  of  the  nervous  system  is  expressed  in  tumors.  In 
general,  however,  both  the  blood  supply  of  the  parts  and  the 
tissue  changes  in  their  parenchyma  cells  are  subservient  to  the 
orders  of  the  nervous  system  ;  inasmuch  as  the  latter  fixes  the 
quantitative  values  of  both,  according  to  the  varying  needs  of 
the  parts  and  the  resources  at  the  disposal  of  the  general 
organism. 

(a)   ANGIO-NEUROSES. 

We  learned  on  p.  17  how  the  blood  supply  of  the  body  is 
regulated  by  that  ingenious  apparatus,  constructed  of  nerves 
and  ganglia,  designed  to  dilate  and  contract  the  blood  vessels. 
It  is,  unfortunately,  so  constituted  as  to  be  easily  deranged 
by  all  sorts  of  pathological  causes,  whereupon  we  have 
hypersemias  and  anaemias,  which  are  entirely  disproportionate 
to  the  needs  of  the  body,  and  form  instead  the  basis  or  con- 
comitants of  a  special  group  of  disturbances,  known  as  angio- 
neuroses.  The  chain  of  causal  phenomena — as  far  as  it  can 
be  distinguished — aims  at  an  irritation  or  paralysis  of  the 
sympathetic.  Occasional  lesions  of  this  nerve  in  the  cervical 
region — in  particular,  gunshot  wounds — have  furnished  ex- 
cellent material  for  analysis  and  diligent  study  on  the  part 
of  our  neuro-pathologists  and  ophthalmologists.  Paralysis, 
and  also  irritation  of  the  cervical  sympathetic,  provoke 
highly  characteristic  groups  of  symptoms,  which  are  seen 
in  a  non-traumatic  and  as  yet  etiologically  unexplained 
angio-neurosis,  known  as  migraine  (hemicrania).  By  this 
term  we  understand  an  intermittent  pain  on  one  side  of  the 
head,  which  attacks  .certain  individuals  periodically,  from 
puberty  up  to  extreme  old  age.  During  the  paroxysm  the 
face  is  usually  pale  and  contracted,  the  eye  on  the  painful 
side  small  and  inflamed,  the  pupil  dilated,  the  temporal  artery 


180  GENERAL   PATHOLOGY. 

tense  and  hard.  In  short,  there  is  a  painful  tetanus  in  the 
cervical  region  of  the  sympathetic  nerve,  with  vasomotor 
paralysis  and  paralysis  of  the  iris.  Later,  the  symptoms  of 
irritation  recede  and  make  room  for  those  of  paralysis  of  the 
sympathetic.  The  latter  are  present  from  the  first  in  rare 
cases  of  hemicrania.  Marked  congestion  of  the  entire  side 
of  the  head  is  accompanied  by  contraction  of  the  pupil,  and 
an  exceedingly  characteristic  slight  droop  of  the  upper  lid 
(ptosis),  with  or  without  increased  secretion  of  sweat. 

Angina  pectoris  is  another  irritation  of  the  sympathetic. 
It  is  accompanied  with  an  accelerated  pulse,  contracted 
peripheral  arteries,  icy  coldness  and  pallor  of  the  extremities, 
and  a  sensation  of  excruciating  pain,  shooting  from  the  sub- 
sternal  region  into  the  left  arm.  This  pain  appears  to  be 
occasioned  by  dilatation  of  the  arch  of  the  aorta,  due  to  the 
recoil  of  the  blood  and  the  subsequent  stretching  and  dis- 
tortion of  the  adjacent  nerve  plexuses. 

Basedow's  disease  is  now  also  reckoned  as  an  angio-neurosi?, 
though  not  as  a  spasm,  but  as  a  paralysis  of  the  cervical 
sympathetic.  A  prolonged  period  of  palpitation  of  the  heart, 
either  with  or  without  cardiac  hypertrophy,  will  be  succeeded 
by  a  swelling  of  the  thyroid  gland,  and  soon  after  by  a 
singular  protrusion  of  the  eyeballs.  The  pulse  reaches  140 
or  even  200  beats  per  minute.  This  disease  arises  in  a  few 
days.  The  strong  pulsation  of  the  thyroid  arteries,  the  loud 
blowing  sounds  heard  over  them,  the  turgescence  of  the  tumor, 
rising  and  falling  in  accord  with  the  intensity  of  the  heart's 
action,  all  convince  us  that  this  is  due  solely  to  a  dilated  con- 
dition of  the  numerous  tributary  vessels  of  the  thyroid  gland. 
The  thyroid  and  the  ophthalmic  arteries  are,  as  we  know,  the 
two  most  valuable  safety-valves  against  congestion  of  the 
brain,  which  may  account  for  the  fact  of  their  being  con- 
jointly implicated  in  this  remarkable  angio-neurosis,  which 
certainly  does  not  implicate  the  entire  cervical  sympathetic. 
The  more  diffused  the  etiological  reflexes,  the  less  apparent 
is  the  participation  of  the  sympathetic.  Other  criteria  are 
then  needed  to  establish  the  "nervous  nature"  of  a  hyper- 
semia  or  anaemia ;  such  are,  the  rapid  appearing  and  dis- 
appearing, the  symmetry  of  the  phenomena,  the  presence  of 
a  neuralgia,  the  dependence  upon  a  contemporary  disorder  in 
another  part  of  the  body,  which  is  especially  to  be  construed 
as  a  reflex  hypersemia  or  ansenria. 


NEURO-VEGETAL   DISTURBANCES.  181 

(6)    TROPHO-NEUROSES. 

In  considering  the  dependence  of  cellular  assimilation  upon 
the  nervous  system,  we  have  repeatedly  indicated  the  value 
of  motor  innervation  in  nourishing  all  those  parenchyma 
cells,  which,  like  the  muscular  fibres,  are  in  their  function 
pre-eminently  assigned  to  the  care  of  the  nervous  system. 
Not  alone  the  need  of  certain  substances  which  are  necessary 
to  restore  their  working  capacities,  but  also  the  power  to  take 
up  these  substances  from  the  blood,  are  increased  through  its 
action.  Undoubtedly  we  have  to  do  with  certain  chemical 
affinities  which  are  satisfied  by  the  taking  up  of  a  little 
albumen,  a  comparative  large  amount  of  fat,  and  still  more 
oxygen,  in  loose  chemical  combination. 

It  is,  perhaps,  allowable  to  assume  a  similar  restorative 
influence  of  centrifugal  innervation  in  the  non-active  muscles, 
but  chiefly  in  all  the  less  active  cells  of  our  organism.  I  sur- 
mise that  there  are  in  the  latter  certain  fibres  of  the  sympa- 
thetic which  have  the  signification  of  trophic  nerve-fibres. 
Farther  than  this  we  cannot  for  the  present  advance,  nor  is 
there  any  support  for  the  supposition  of  a  hunger  in  the  cells, 
whose  demands  are  conveyed  to  the  central  nervous  system 
by  sensitive  nerves.  It  is  at  present  of  more  consequence  to 
attribute  the  disordered  condition  of  the  tissues  to  the  accumu- 
lated products  of  excretion  and  exhaustion,  and  to  look  for 
relief  in  the  rapid  rinsing  of  the  tissues  with  arterial  blood, 
brought  about  by  reflex  action.  This  theory  would  also 
require  sensitive  nerve  fibres,  which,  on  account  of  their 
assistance  to  nutrition,  we  might  also  call  trophic.  We  shall 
be  inclined  to  dispute  the  identity  of  these  sensitive  trophic 
nerves  with  the  connective  tissue  nerves  described  on  p.  17, 
but  must  not  forget  that  the  irritation  of  the  sensitive  nerves 
which  execute  the  animal  functions  is  also  able  to  produce 
hypersernias.  We  must,  accordingly,  ascribe  trophic  functions 
to  these  latter  as  well,  although  not  in  the  same  degree 
as  those  we  ascribed  before  to  the  animal  motor  nerves. 

From  these  premises  we  may  conclude : — 

(1)  That,  in  view  of  our  imperfect  knowledge  of  trophic 
nerves,  strictly  speaking,  and  the  difficulty  of  defining  their 
territory,  it  is  not  possible  or  allowable  to  pronounce  upon 
independent  tropho-neu roses  with  any  degree  of  precision. 

(2)  That  we    may  look    for    tropho-neu  roses  in  all   pro- 
longed disturbances  of  the  sensory -motor  apparatus. 


182  GENERAL   PATHOLOGY. 

(3)  That  no  radical  differences  appear  as  regards  the 
quality  of  the  disturbances,  but  they  all  have  something  to 
do  with  a  certain  plus  or  minus  of  the  factors  of  nutrition 
which  are  subject  to  nervous  control. 

These  expectations  are  confirmed  by  actual  knowledge. 
Those  longest  known  and  most  intelligible  to  us  are  the  nutri- 
tive disturbances,  which  appear  concomitantly  in  all  the  ele- 
mentary forms  of  sensory-motor  disturbances,  provided  that 
the  latter  are  of  some  duration.  Reference  may  here  be  made 
to  the  descriptions  in  Paralysis;  trophic  disturbances  were 
also  mentioned  under  anaesthesia,  as  well  as  under  neuralgia 
and  convulsions. 

The  disturbances  themselves  always  follow  the  same  course. 
Simple  atrophy  of  the  chief  cells  of  the  diseased  part  either  may 
or  may  not  be — according  to  the  seat  of  disease — associated 
with  a  permanent  dilatation  of  the  local  blood  vessels.  As  this 
dilatation  is  not  the  result  of  a  temporary  inhibition,  but  of 
a  permanent  muscular  paralysis,  it  gradually  assumes  a  more 
stationary  character.  It  becomes  the  starting  point  for  a 
progressive  hypertrophy  of  the  connective  tissues,  such  as  may 
be  seen  in  any  prolonged  venous  hypenemia.  There  is  also 
a  singular  display  of  non-resistance  in  the  attitude  of  the  im- 
perfectly innervated  parts  towards  external  irritations.  This 
incapacity  for  resistance  is  seen  in  various  degrees  of  intensity, 
from  a  certain  "  marked  inflammability  "  up  to  "  gangrene." 
I  explain  this  as  follows  : — 

The  original  disease  has  impaired  the  capacity  of  the  central 
organ  for  the  reception  of  the  centripetal  accessions,  so  that 
the  peripheral  parts  are  unable  to  surrender  their  customary 
quota  of  excitation  to  the  central  nervous  system,  and  are 
forced  involuntarily  to  react  with  their  whole  strength  upon 
themselves.  All  tropho-neuroses,  however,  are  composed  of 
the  three  above-named  factors  and  their  results,  as  the  fol- 
lowing consideration  will  show. 

Beginning  with  the  "  concomitant  tropho-neuroses,"  we 
accord  the  first  place  to  the  atrophy  of  inactivity  of  the  muscles. 
We  have  already  noted  the  appearance  of  the  same,  after 
section  of  the  peripheral  nerves,  and  studied  the  results  and 
nature  of  the  vasomotor  paralysis,  which  is  induced  by  sim- 
ultaneous separation  of  the  vasomotor  nerves  (p.  248).  Vas- 
cular paralysis  usually  is  absent  when  the  muscular  paralysis 
originates,  let  us  say,  in  the  spinal  marrow,  and  not  in  a 


NEURO- VEGETAL   DISTURBANCES.  183 

mechanical  injury  of  the  different  nerves.  This  is  the  case 
in  spinal  paralysis  of  children,  and  probably  also  in  pro- 
gressive atrophy  of  the  voluntary  muscles,  which  commonly 
begins  with  emaciation  of  the  muscles  of  the  thumb,  and  also 
in  saturnine  paralysis.  When  the  immobility  of  the  muscles 
is  compulsory  and  non-nervous,  as  in  pathological  rigidity  of 
certain  joints,  the  muscular  fibre  withstands  the  inaction- 
atrophy  for  a  long  time.  Its  final  disappearance  is  associated 
with  a  new  formation  of  fatty  tissues,  which  may  be  a  sign  of 
the  continuance  of  such  nutritive  processes,  at  least,  as  are 
not  essentially  muscular,  being  due  perhaps  to  the  agency  of 
the  sympathetic.  Similar  effects  are  visible  in  artificial  fat- 
tening, and  in  that  mysterious  atrophy  of  the  muscular 
system  which,  occurring  chiefly  in  the  lower  extremities  of 
half-grown  boys,  has  been  named,  on  account  of  the  prolific 
interstitial  formation  of  fat,  Pseudo-Hypertrophia  Lipo- 
matosa. 

In  addition  to  these  processes  in  the  muscles  themselves, 
there  occur  in  peripheral  paralysis  certain  changes  in  the 
skin,  which  we  can  only  judge  from  the  standpoint  of  dimin- 
ished nutrition.  The  skin  often  becomes  thin,  smooth  and 
glossy,  especially  about  the  fingers  (glossy  fingers).  The 
epidermis  is  not  properly  attached  to  the  surface  of  the  papil- 
lary layer,  and  scales  off  easily,  or  forms  vesicles,  which  con- 
tain a  serous  fluid.  The  nails  grow  thick  and  become  curved ; 
often,  indeed,  separate  wholly  from  the  matrix.  The  hair 
drops  out,  etc.  The  deeper  parts,  such  as  the  bones  and  joints, 
tend  to  atrophy,  while  the  loose  connective  tissue  begins, 
under  the  auspices  of  the  vascular  paralysis,  to  proliferate, 
threatening  the  paralyzed  limb  with  general  cirrhosis. 

The  feeble  resistance  which  the  paralyzed  parts  oppose  to 
external  lesions  is  most  surprising.  Trifling  injuries  and 
insignificant  chemical  and  thermal  irritants  of  various  kinds 
produce  at  once  tedious  ulcerations.  Gangrene  (Decubitus 
paralyticus)  is  easily  acquired  and  progress  rapidly. 

As  previously  stated,  I  ascribe  this  latter  series  of  phe- 
nomena to  the  simultaneous  paralysis  of  sensation,  which  is 
never  lacking  in  peripheral  paralyses.  This  view  is  supported 
by  the  fact  that  just  this  paralysis  is  especially  conspicuous  in 
isolated  sections  of  sensitive  nerves.  Thus,  in  rabbits,  the 
section  of  the  ophthalmic  branch  of  the  trigeminal  nerve 
produces  in  the  corresponding  eye  a  predisposition  towards 


184  GENERAL   PATHOLOGY. 

inflammation,  which  leads  inevitably  to  ulceration  of  the 
cornea,  conjunctiva,  etc.,  unless  the  eye  be  shielded  from  ex- 
ternal irritants.  Section  of  both  pneumogastric  nerves  is 
likewise  followed  by  a  condition  of  inflammability  in  the  lung, 
whence  develops  rapidly  a  pneumonia,  due  to  the  irritation  of 
the  liquids  of  the  mouth,  which  are  unhindered  from  flowing 
into  the  bronchi. 

Convulsions  and  hypersesthesia  may  at  times  also  lead  to 
trophical  disturbances,  but  this  is  in  rare  cases,  where  they 
appear  as  persistent  affections. 

The  more  "  independent  tropho-neuroses  "  include  any  num- 
ber of  atrophies,  inflammations,  and  gangrenous  processes. 
Their  whole  aspect  intimates  the  participation  of  the  nervous 
system,  although  it  cannot  as  yet  be  satisfactorily  proved  that 
they  originate  in  any  definite  local  alterations  of  the  same. 
Among  simple  atrophies  we  may  specify  those  which  attack 
one-half  of  the  face  and  extremities ;  those  causing  sudden 
whitening  of  the  hair,  from  fright  and  anxiety ;  those  causing 
loss  of  hair  in  patches  in  what  is  called  the  area  Celsi,  and  the 
scattered  white  patches  in  chorea  minor. 

The  most  perplexing  of  all  are  certain  inflammations  of  the 
skin  which  coincide  to  all  appearances  with  affections  of  sen- 
sitive nerves,  particularly  herpes  zoster.  Violent  itching 
accompanies  the  appearance  upon  the  skin,  over  the  course  of 
certain  sensitive  nerves,  of  a  group  of  pearl-sized  vesicles. 
Their  arrangement  marks  very  distinctly  the  course  of  the 
nerve — for  example,  that  of  an  intercostal  nerve.  After  a 
few  days  they  dry  up  and  heal  over.  Von  Barensprung  and 
von  Recklinghausen  have  discovered  in  this  disease  an  in- 
flammatory redness  of  the  corresponding  intercostal  nerves 
and  of  the  intervertebral  ganglion,  and  this  very  nearly  estab- 
lishes the  participation  of  the  sensitive  nerves  in  the  formation 
of  these  vesicles.  "  Psoriasis  cutanea,"  which  is  marked  by 
the  presence  of  numerous  red  and  slightly  swollen  patches 
and  abundant  epidermic  products,  also  hints  at  a  nervous 
origin,  by  the  symmetry  of  the  exanthema  which  often  breaks 
out  on  the  back.  It  may  pass  for  a  statement  subject  to  many 
limitations,  when  I  ascribe  these  neurogenous  inflammations  to 
the  confluence  of  two  etiological  influences,  each  of  which 
would  of  itself  be  insufficient  to  achieve  the  same  result.  These 
are  (1)  an  angio-neurosis,  or,  at  least,  a  tendency  towards 
vascular  dilatation,  due  to  the  local  derangement  of  certain 


NEURO-VEGETAL   DISTURBANCES.  185 

sensitive  centres;  (2)  an  accumulation,  as  in  the  case  of 
trigetninal  ophthalmia,  of  the  usually  ineffectual  irritants  of 
the  skin,  which,  on  account  of  a  local  affection,  cannot  be 
discharged,  and  hence  produce  a  much  more  powerful  local 
effect. 

To  the  latter  agency  we  may  refer  all  cases  of  "  neurotic 
gangrene,"  whose  whole  expression  and  diffusion  are  suggestive 
of  decubitus  paralyticus,  water  cancer  (c.  aquaticus,  Noma), 
mal perforant  du  pied,  symmetrical  gangrene  of  the  face,  and 
leprous  necrosis,  where  the  insufficient  centripetal  removal 
of  peripheral  irritation  is  especially  conspicuous  in  the  anses- 
thesia  produced  by  leprous  neuritis,  which  accompanies  it. 


IV.    SPECIAL   PAKT. 


The  species  morbi  is  determined  by  the  cause  of  disease, 
on  which  depends  the  point  of  attack — and  I  might  almost 
say — the  entire  plan  of  attack  of  a  disease.  The  cause  of 
disease  regulates  the  order  and  the  manner  in  which  the 
organs  shall  be  attacked ;  whether,  and  at  what  time  fever 
shall  set  in,  as  well  as  the  intensity  and  particular  type  of 
the  same;  and  the  degree  of  injury  to  the  heart  and  senso- 
rium.  The  cause  of  disease,  in  short,  includes  everything  by 
which  we  distinguish  one  disease  from  another.  There  is  no 
other  distinction  but  that  of  cause,  which  furnishes  those 
peculiarities  of  diseases,  by  which  they  can  be  readily  classified 
into  major  and  minor  varieties. 

It  is,  of  course,  understood  that  such  a  classification  is  only 
concerned  with  the  actual  and  genuine  causes  of  disease, 
excluding  all  that  is  casual  and  irregular.  We  can  conceive 
of  an  etiological  division  of  diseases  which  would  be  governed 
by  the  vehicle  through  which  the  disease  is  conveyed  to  us. 
In  such  a  case  we  would  have  nutritive  diseases,  infectious 
diseases,  climatic  diseases,  diseases  due  to  certain  vocations, 
etc.  This  system,  although  etiological,  is  purely  artificial, 
and  could  not,  for  a  moment,  be  seriously  entertained.  The 
following  pages  are  devoted  almost  exclusively  to  the  question 
of  food,  clothing,  atmosphere  and  infection.  Natural  groups 
of  diseases  are  only  formed  when  we  adopt  as  the  standard  of 
division  the  independent  agency  of  the  cause  of  disease  as 
well  as  its  quality  and  natural  history  existence. 

Thus  we  have  five  chief  classes,  to  which  there  is  at  present 
added  a  sixth,  Idiopathic,  i.  e.,  diseased  conditions  whose  causes 
are  as  yet  unknown. 

(1)  Traumatic  diseases;  (2)  Parasitic  disease;  (3)  Dis- 
eases due  to  defective  nutrition  and  growth ;  (4)  Diseases  of 
over-exertion  ;  (5)  Diseases  of  premature  senility. 

It  not  unfrequently  happens  that  several  distinct  diseases 
occur  in  one  individual.     In  such  cases  clinical  analysis  is  not 
content  merely  to  notice  the  various  concurrent  etiological 
186 


TRAUMATIC   DISEASES.  187 

phenomena,  but  it  makes  them  of  first  importance  in  diagnosis, 
prognosis  and  therapeutics.  Thus  it  is  evident  that  medical 
instinct  has  long  since  accustomed  itself  to  perceive  in  any 
given  illness  a  plurality  of  diseases.  Such  a  patient  represents 
to  us,  not,  as  he  imagines,  one  disease,  but  several  diseases, 
whose  symptoms  either  co-exist  independently,  or  interfere 
with  each  other,  and  furnish  products  of  amalgamation. 

I.  TRAUMATIC  DISEASES. 

Trauma,  in  its  broadest  sense,  is  any  external  attack  which 
forcibly  alters  the  physical  or  chemical  composition  of  a  part 
or  the  whole  of  the  body.  Hence  we  distinguish  mechanical, 
chemical,  electrical  traumata,  and  traumata  due  to  the 
extremes  of  heat  or  cold. 

(a)   MECHANICAL  TRAUMA. 

In  order  to  comprehend  the  attitude  of  the  body  towards 
the  various  mechanical  assaults  to  which  it  is  exposed,  we 
must  first  of  all  concede  that,  in  structure  and  texture,  it  is 
so  ingeniously  contrived  as  to  offer  the  greatest  possible  re- 
sistance to  mechanical  agencies.  The  brittle  and  sensitive 
bones  are  generally  enveloped  in  a  thick  sheath  of  soft  elastic 
substances,  and  the  skin  is  of  such  decided  elasticity  and 
firmness  that  it  resists  the  pressure  of  a  blunt  surface  by  an 
incredible  amount  of  stretching,  even  allowing  brief  but 
extensive  displacements  of  the  subcutaneous  parts  without 
itself  becoming  lacerated.  But  everything  has  its  limit,  and 
there  are  a  series  of  mechanical  traumata  which  effect  a  per- 
manent breach  of  continuity ;  such  are  incisions,  bites  and 
lacerations,  blows,  knocks,  stings,  contusions  and  falls. 

"  Solution  of  continuity  "  is  the  first  and  general  result  of 
every  mechanical  trauma.  This  is  usually  well  marked  when 
the  parts  are  really  cut  with  a  sharp  instrument,  or  in  a 
genuine  fracture  of  the  bones.  There  are  bruises  and  contu- 
sions which  produce  solutions  in  continuity  in  the  more 
delicate 'structural  parts,  where  the  pathological  condition  is 
not  at  all  perceptible  immediately  after  the  injury.  In  such 
instances  the  depth  of  the  lesion  inflicted  can  only  be  judged 
by  the  irrevocable  loss  of  function  (commotio  cerebri)  or  by 
the  gangrene  which  at  once  sets  in  (subcutaneous  contusions, 
as  in  kicks  from  a  horse).  Apart  from  these,  we  must  con- 
sider, in  a  fresh  wound :  the  amount  of  blood  lost  or  still 


188  GENERAL  PATHOLOGY. 

escaping ;  the  possibility  of  air  or  fat  entering  the  blood  paths ; 
the  loss  or  destruction  of  tissue ;  the  entrance  of  foreign  sub- 
stances into  the  wound  ;  and,  finally,  the  quality  of  the  injured 
parts,  which  determines  on  the  one  hand  the  value  of  the 
functional  disturbance,  on  the  other  the  local  probabilities  of 
recovery. 

The  reunion  of  the  divided  parts,  their  restitution  as  a  scar, 
the  closing  up  of  the  bodily  parenchyma  exposed  by  the 
wound — in  short,  the  healing  of  the  lesion — is  not  so  much  the 
deliberate  intention  of  the  recuperative  powers  of  nature  as  it 
is  the  result  of  an  inflammatory  process,  which  has  been 
induced  by  the  mechanical  irritation  of  the  parts.  A  hyper- 
semia  of  the  remaining  intact  blood  vessels  leads  to  a  sero- 
cellular  exudation,  which  is  directed  from  all  quarters  towards 
the  injured  spot.  Here  the  exudate  reaches  those  portions  of 
the  tissues  whose  nutrition  has  been  threatened  by  the  trau- 
matic lesions  which  they  have  suffered.  In  favorable  cases, 
we  have  to  do  with  but  a  thin  tissue  stratum,  which,  when 
the  parts  are  properly  and  promptly  approximated,  can  be 
nourished  by  the  aid  of  the  exudate,  until  a  sufficient  number 
of  new  formed  vessels,  together  with  a  moderate  supply  of 
connective  tissue,  reunite  the  edges  of  the  wound  (union  by 
first  intention).  In  less  favorable  cases,  both  large  and  small 
shreds  of  tissue  undergo  necrosis,  and  must,  together  with  all 
other  foreign  matters,  be  loosened  and  removed  before  the 
edges  can  reunite.  The  cleansing  and  healing  up  of  the 
wound  by  second  intention  is  accomplished  by  granulation 
tissue,  which  establishes  a  layer  of  pus  at  the  junction  of  the 
healthy  and  necrosed  parts,  separating  the  two,  but  soon 
leading  to  cicatrization.  The  epithelial  covering  of  the 
surface  is  derived  from  the  surrounding  epithelial  borders. 

Disturbances  in  these  processes  are  mainly  due  to  the  deposi- 
tion in  the  wound  of  a  cleft  fungus,  Billroth's  cocco-bacteria 
septica.  Since  we  have  learned  from  Lister  how  to  frustrate 
the  poisonous  influence  of  this  fungus,  exerted  upon  the  blood 
and  juices  of  the  body,  wounds  complicated  with  septicaemia, 
pyaemia,  diphtheria,  and  erysipelas  are  exceptional ;  in  resi- 
dences and  towns  they  no  longer  occur  epidemically.  A 
more  careful  discussion  of  this  subject  will  be  found  under  the 
head  of  infectious  diseases. 

Thrombosis  and  embolism  are  favorite  elements  of  pyaemia, 
to  which  they  impart  a  metastatic  character.  They  appear, 


TRAUMATIC    DISEASES.  189 

however,   at   times   independently,  in    traumatic    inflamma- 
tions. 

We  must  not  omit  to  mention  trismus  and  tetanus,  of  which 
we  have  already  spoken,  as  important  and  dangerous  compli- 
cations even  of  small  and  cicatrized  wounds. 

(6)    CHEMICAL   TRAUMA. 

Our  body  is  likewise  protected  against  the  inroads  of  chemi- 
cal injuries.  The  horny  layer  of  the  epidermis,  with  its  won- 
derful impermeability  and  great  power  of  resistance,  is  cer- 
tainly the  best  possible  protection  against  the  most  powerful 
acids  and  alkalies.  But  there  is  a  limit  to  everything,  and 
the  protective  power  of  the  horny  layer  of  the  epidermis  is 
limited  both  by  time  and  space.  It  can  only  withstand  a 
brief  contact  with  the  more  powerful  chemical  reagents,  and 
the  protective  power  of  the  horny  layer  does  not  extend 
beyond  its  territory.  Beyond  the  territory  of  the  teeth  and  the 
entrance  to  the  nares  the  case  is  different.  Chemical  processes 
take  place  in  the  stomach  and  the  intestinal  canal ;  solid  bodies 
undergo  decomposition  and  liquefaction,  and  are  able  and  even 
compelled  to  pass  into  the  body  through  convenient  channels. 
The  mucous  membrane  of  the  stomach  and  intestines  is  so 
constructed  as  to  facilitate  such  an  entrance.  The  sense  of 
taste  usually  gives  warning  of  the  reception  of  injurious 
ingesta,  but  if  it  fail  to  do  so,  and  the  warning  pass  unheeded, 
there  is  nothing  to  prevent  the  dangerous  substances  from 
eventually  penetrating  into  the  blood  and  from  thence  into 
the  entire  body,  in  the  same  manner  as  food  and  drink.  Even 
the  squamous  epithelium  of  the  mouth  and  oesophagus  are 
more  vulnerable  to  chemicals  than  the  epidermis,  and  beyond 
the  cardia  the  epithelium  affords  absolutely  no  protection. 

The  organism's  system  of  defence  against  pernicious  gases  is 
still  weaker.  The  mouth  can,  at  least,  be  kept  closed  when 
necessary,  but  if  we  would  not  suffocate,  we  must  inhale  per- 
nicious gases.  We  have  yet,  to  be  sure,  the  sense  of  smell  as 
a  sentinel,  but  this  sense  has  become  so  badly  contaminated  by 
the  advance  of  culture,  by  cohabitation  and  division  of  labor, 
that  the  individual  of  to-day  regards  his  nose  as  a  generally 
useless  and,  in  view  of  ceaseless  catarrhs,  troublesome  organ. 
Thus  we  inhale,  nolens  volens,  every  noxious  gas  which  asso- 
ciates itself  with  the  indispensable  oxygen.  Not  all  of  the 
particles  of  dust  which  pass  into  the  respiratory  tract  adhere 


190  GENERAL   PATHOLOGY. 

to  the  moist  walls  of  the  same  and  are  again  expelled  into  the 
outer  air  by  the  motion  of  the  cilia  lining  the  cylindrical 
epithelium.  Some  of  them  penetrate  as  far  as  the  wall  of  the 
alveoli  and  pass  into  the  lymph  vessels  and  glands  of  the 
lungs.  Here  they  obstruct  the  absorbent  system  of  the  organ, 
if  they  do  not  go  further  and  produce  chronic  inflammation 
and  suppuration  (Anthracosis,  Siderosis,  etc).  The  patho- 
genetic  microphytes  follow  the  same  path,  although  they 
appear  to  pass  more  directly  into  the  blood  ;  their  subsequent 
operation  evinces,  at  any  rate,  that  very  few  have  remained 
any  length  of  time  in  the  lung. 

But  to  return  to  chemical  trauma.  It  is  based  upon  the 
fact  that  the  normal  chemical  structure  of  the  bodily  parts  is 
either  permanently  or  temporarily  destroyed  by  the  influence 
of  some  fluid  or  gaseous  substance,  which  already  possesses 
unsatisfied  chemical  affinities,  or  develops  the  same  at  the 
moment  of  attack.  The  slightest  degree  of  chemical  action 
may  be  said  to  exist  when  the  chemical  continuity  of  the  part 
attacked  is  merely  threatened,  which  results  in  a  firmer  union 
of  its  molecular  structure ;  in  other  words,  when  the  chemical 
irritation  rouses  the  physiological  action  of  the  involved  bodily 
parts  (exciting  influence).  When  this  irritation  oversteps  a 
certain  limit  of  time  and  intensity,  the  heightened  action 
develops  into  the  opposite  extreme,  that  of  paralysis  (indirect 
benumbing  influence).  Occasionally  the  attack  is  so  powerful 
that  the  phenomenon  of  heightened  activity  does  not  appear 
at  all  (direct  benumbing).  The  first  stages  of  a  process 
of  a  more  lasting  chemical  metamorphosis  now  begin.  As 
only  a  portion  of  the  molecular  structure  is  at  first  involved, 
assimilation  is  able,  with  the  aid  of  the  injured  parts  and 
their  gradual  restoration,  to  repair  the  damage.  In  the  later 
stages  we  find  an  irrevocable  change  in  the  entire  molecular 
structure,  which  entails  a  definite  exclusion  of  the  part  from 
the  organic  whole.  The  latter  may  take  place  immediately 
(necrosis,  mortification,  caustic  action),  or  so  spread  that  the 
actual  advent  of  death,  L  e.,  the  separation,  is  merely  a  ques- 
tion of  time. 

In  reviewing  the  great  number  and  diversity  of  the  chemical 
agencies  here  concerned,  and  also  the  widely  differing  chemical 
contexture  of  the  body,  the  inference  is  natural  .that  these  dis- 
similarities might  prove  a  closer  affinity  between  certain 


TRAUMATIC    DISEASES.  191 

chemical  agencies  and  certain  tissues  and  organs  of  the  body. 
This  inference  is  found  to  be  correct,  for  we  see  that  when  a 
chemical  body  is  brought  into  contact  at  the  same  time  and 
in  the  same  form  with  all  the  organs  and  tissues  of  the  body, 
a  selection  generally  takes  place,  by  means  of  which  some 
organs  and  tissues  exhibit  a  decided  preference  for  the 
chemical  body.  All  degrees  of  chemical  combinations  may 
be  present  at  this  particular  point,  while,  perhaps,  other 
organs  and  tissues  take  no  active  part.  Such  a  case  is,  how- 
ever, only  supposable  when  the  chemical  body  has  really  been 
absorbed  through  the  channels  already  mentioned,  when, 
after  passing  through  the  stomach,  intestines  or  lung  it  reaches 
the  blood,  and  is  diffused  by  the  same  throughout  the  body. 
That  many  chemical  bodies  have  already  entirely  or  in  part 
satisfied  their  free  affinities  is  proved  by  the  ordinary  fate  of 
the  very  strongest  mineral  acids,  which  immediately  enter 
into  such  close  union  with  the  membranes  of  the  organs  of 
deglutition  and  the  stomach  that  nothing  remains  for  re- 
sorption. 

Finally,  the  significance  of  the  chemical  attack  in  relation 
to  the  remaining  organism  is  determined  exactly  :  (1)  by  the 
physiological  importance  of  the  organ  attacked ;  (2)  by  the 
extent  of  the  change  undergone.  Inasmuch  as  both  of  these 
are  regulated  by  the  quality  of  the  incorporated  chemical 
body,  and  the  manner  of  its  incorporation,  and  both  of  these 
factors  are  usually  evident,  we  are  enabled,  in  most  cases,  to 
predict  with  reasonable  certainty  the  result  of  the  incorpora- 
tion. Thus  we  arrive  at  the  great  and  important  subject  of 
the  science  of  poisons,  and  at  the  same  time  of  that  of  chemi- 
cal remedies.  The  foregoing  reflections  have  fully  prepared 
us  to  investigate  the  countless  chemically-operative  substances 
furnished  us  by  nature,  in  all  their  varied  effects,  either  as 
remedies  or  poisons. 

For  practical  purposes,  we  are  in  the  habit  of  separating 
poisons  from  remedies,  and  since  pathology  deals  properly  only 
with  the  intoxications,  we  should  be  justified  in  following  the 
above  division.  But  it  is  plainly  a  more  scientific  method  to 
consider  individually  each  chemical  body,  and  after  a  careful 
analysis  of  its  constituents,  formation,  or  origin,  to  state  where 
and  how  it  approaches  the  human  body,  and  the  local  results 
developed  in  consequence ;  also,  whether  and  under  what  cir- 
cumstances it  is  received  into  the  blood,  and  what  are  the 


192  GENERAL   PATHOLOGY. 

chosen  seats  of  its  chemical  activity.  Lastly,  we  shall  consider 
the  varying  degrees  of  its  influence,  and  always  determine  in 
what  quantity  it  may  be  incorporated  as  a  remedy,  and  in  what 
amount  as  a  poison. 

(c)    THERMAL   TRAUMA. 

(1)  Increase  of  Bodily  Temperature, 

In  treating  the  subject  of  fever,  we  had  frequent  occasion 
to  mention  the  heat-regulating  apparatus,  that  interesting 
mechanism  whose  design  is  to  protect  the  animal  body  against 
the  injurious  consequences  of  the  extreme  variations  in  tem- 
perature to  which  our  atmosphere  is  exposed  at  every  point  of 
the  earth's  surface.  We  regarded  it  as  an  undivided  whole, 
whose  action  upon  the  entire  or  a  part  of  the  body  is  regulated 
by  the  perception  of  a  greater  or  smaller,  general  or  local  loss 
of  heat. 

A  general  checking  of  the  escape  of  heat  is  most  effectually 
accomplished  by  an  unusual  elevation  of  the  external  tem- 
perature. This  is  resisted  by  the  heat-regulating  apparatus, 
first  of  all,  by  an  increased  fullness  in  the  blood  vessels  of  the 
skin,  and  later,  by  the  secretion  of  sweat  and  its  evaporation. 
The  process  is  assisted  instinctively  on  our  part  by  cessation 
from  physical  labor  and  by  wearing  thin  clothing.  These 
means  are,  however,  insufficient  when  the  outer  temperature 
greatly  exceeds  that  of  the  body,  when  evaporation  is  checked 
by  a  calm  and  very  moist  atmosphere,  or  when  the  bodily 
temperature  is  abnormally  raised  by  violent  muscular  activity. 
Under  such  circumstances  day-laborers,  pedestrians,  or  march- 
ing soldiers  may  become  overheated  and  suffer  sunstroke 
(Insolatio)  when  the  temperature  is  not  over  30°  or  36°  C. 
(86°  to  96.8°  F.)  The  rapid  increase  of  the  blood  heat  to  40° 
C.,or  44°  C.(104°  F.to  111.2°  F.),  brings  about  an  over-irri- 
tation of  the  central  nervous  system,  which  is  ushered  in  by  a 
warning  phase  of  irritation.  The  latter  is  expressed  by  a  loss  of 
appetite  and  nausea,  followed  by  hallucinations  and  mental  dis- 
turbances with  suicidal  impulses.  The  attack  itself  is  marked 
by  a  sudden  loss  of  consciousness.  The  sufferer  falls  down  in- 
sensible, the  pulse,  which,  in  the  prodromal  stage  was  full  and 
hard,  is  raised  to  140  or  160  feeble  and  scarcely  perceptible  beats. 

The  imperfect  contractions  of  the  heart  occasion  general 
cyanosis,  which  is  found,  especially  after  death,  well  marked 
in  the  brain  and  lungs.  Death  ensues  from  pulmonary 


TRAUMATIC    DISEASES.  193 

cederaa.  The  temperature  frequently  continues  to  rise  after 
death — often  an  entire  degree.  Decomposition  sets  in  very 
soon.  An  astonishing  number  of  colorless  blood  corpuscles 
are  found  in  the  varnish-colored  blood. 

The  local  retention  of  heat  produces  at  first  the  same  results 
as  the  general.  There  is  a  local  hypersemia  accompanied  by 
intense  redness  of  the  skin  and  secretion  of  sweat.  When, 
however,  the  impeded  escape  is  substituted  by  an  unavoidable 
accession  of  heat,  exceeding  all  physiological  limits,  we  obtain 
those  local  affections  of  the  skin  and  underlying  parts  known 
as  burns.  In  this  case  the  accession  of  heat  appears  as  an  in- 
flammatory irritant.  We  distinguish  three  degrees  of  burns, 
according  as  the  inflammatory  irritant  produces  a  permanent 
redness  of  the  skin,  vesication,  or  callosities.  The  local 
effects  of  these  higher  grades  of  thermal  trauma  do  not  differ 
from  the  corrosive  effects  of  chemical  bodies  and  present  the 
same  objective  points  to  medical  diagnosis.  This  is  especially 
true  of  cases  where  the  burn  involves  a  large  portion  of  the 
surface  of  the  skin.  If  a  third  or  more  of  the  skin  be  burnt 
or  destroyed  by  caustics,  there  follows  an  inevitable  although 
gradual  cooling  off  of  the  blood,  which,  at  32°  C.  (89.6°  F.), 
or  30°  C.  (86°  F.)  is  fatal  to  life.  No  increased  production 
and  no  economizing  of  heat,  however  ingenious,  can  compen- 
sate for  the  extraordinary  loss  which  occurs  through  the 
hypersemic  portions  of  the  bodily  surface  which  have  been 
robbed  of  the  protecting  epidermis. 

2.  Decrease  of  Bodily  Temperature. 

Here,  also,  we  find  both  a  general  and  a  local  escape  of 
heat.  We  are,  in  the  main,  well  protected  against  the  de- 
crease of  the  normal  heat  of  the  body  produced  by  the  lower- 
ing of  the  outer  temperature.  Slight  variations  of  temperature 
are  equalized  by  the  activity  of  the  heat-regulating  apparatus ; 
the  higher  degrees  of  cold  are  averted  by  warm  clothing, 
which  answers  every  purpose. 

The  influence  of  a  periodical,  moderate  fall  in  external 
temperature  is  extremely  beneficial  to  the  body.  In  order  to 
diminish  the  escape  of  heat,  the  muscular  fibres  and  arteries 
of  the  skin  contract,  and  the  blood  is  thus  forced  toward  the 
central  organs.  The  blood  supply  of  the  heart,  lungs,  brain 
and  liver,  becomes  increased,  and  they  become  capable  of 
increased  activity.  The  heart  beats  more  rapidly,  the  respira- 


194  GENERAL   PATHOLOGY. 

tions  are  more  frequent  and  deeper.  The  blood  being  loaded 
with  oxygen,  the  well-fed  brain  experiences  a  wonderful  sense 
of  vigor  and  freshness.  A  repetition  of  this  condition  at 
proper  intervals  furnishes  a  powerful  impetus  to  the  entire 
nutritive  system.  A  reserve  supply  of  fat  is  stored  up,  and 
the  functions  of  the  brain  are  strengthened ;  we  have,  in 
short,  all  the  curative  effects  produced  by  the  well  known  cold 
water  and  fresh  air  cures. 

Let,  however,  this  general  withdrawal  of  heat  overstep  a 
certain  limit,  and  there  follows  over-irritation  and  weakening 
of  the  functions  of  the  central  nervous  system,  in  particular 
of  the  spinal  marrow,  which  appears  singularly  sensitive  to 
excessive  cold. 

The  acme  of  the  changes  is  reached  in  death  by  freezing, 
when  neither  the  heat-regulating  apparatus  nor  additional 
clothing  have  been  able  to  maintain  the  requisite  temperature 
of  the  blood.  The  diminished  excitability  of  the  central 
nervous  system  is  apparent  in  the  enfeebled  heartbeats  and 
respiration,  as  well  as  in  the  feeling  of  exhaustion  which 
rapidly  increases  and  urges  the  unfortunate  victim  to  seek 
relief  in  sleep.  The  degree  of  exhaustion  is  greater,  the 
greater  the  preceding  excitation.  The  latter  is  due  to  the 
forcing  back  of -the  blood  from  the  surface  to  the  brain,  and 
conspicuously  to  the  use  of  alcohol,  which  in  itself  reduces 
the  temperature  of  the  blood,  so  that  everything  combines  to 
explain  the  well-known  fact  that  death  by  freezing  very  fre- 
quently overtakes  drunkards. 

The  most  palpable  effect  of  a  local  withdrawal  of  heat  is 
the  freezing  of  individual  parts  of  the  body.  Although  we 
are  able  to  sufficiently  shield  the  greater  part  of  the  body 
from  the  effect  of  a  very  low  temperature,  it  is  impossible 
to  protect  all  portions  equally  well.  We  must  see,  hear, 
breathe  and  use  our  hands  and  feet,  in  spite  of  the  cold. 
Thus  it  happens  that,  in  rigorous  weather,  our  noses,  ears, 
fingers  and  toes  are  liable  to  be  frozen. 

The  next  result  of  the  local  withdrawal  of  heat  is  a  con- 
traction of  all  the  smooth  muscular  fibres  of  the  skin,  of  the 
media  vasorum,  and  the  erector  papillae  muscles.  The  skin 
becomes  pale  and  shriveled,  the  fingers  and  toes  white  and 
cold  as  marble.  It  is  assumed  that  irritation  from  cold  incites 
at  once  muscular  contraction.  This  contraction  is  as  pur- 
poseless as  the  contraction  of  the  same  structure  in  intermittent 


TRAUMATIC    DISEASES.  195 

fevers.  It  would  be  plainly  much  more  practical  to  allow 
the  blood  to  flow  through  the  gaping  blood  vessels  of  the 
threatened  territory  in  a  full  and  rapid  stream,  replacing  in 
this  manner  the  previous  loss  of  heat.  Fortunately,  there  is, 
in  most  cases,  an  almost  immediate  over-irritation  and  relaxa- 
tion of  the  muscular  fibres,  by  means  of  which  the  desired  con- 
dition accomplishes  itself.  Furthermore,  there  is  a  tickling 
sensation  in  the  parts  as  they  grow  cold,  which  often  becomes 
so  painful  that  we  are  led  to  employ  mechanical  irritation,  such 
as  pressing,  rubbing  and  stamping.  This  induces  an  arterial 
hypersemia  which  speedily  terminates  the  athermic  irritation. 

Freezing  does  not  occur  until  the  over-irritation  and 
counter-irritation  already  mentioned  are  withdrawn,  or  until, 
in  spite  of  the  abundant  supply  of  warm  blood,  the  cooling 
off  of  the  parts  continues  until  a  pitch  is  reached  where  a  per- 
manent molecular  alteration  of  the  tissues  is  established.  The 
nature  of  this  alteration  is  unknown.  To  designate  it  as  vita 
minor  is  a  simple  confession  of  ignorance.  It  is  expressed  in 
various  disease-pictures,  whose  complete  unity  and  indi- 
viduality are  not  apparent  until  the  effect  of  the  cold  has 
passed  away,  and  the  frozen  part  begins  to  return  to  its 
normal  condition. 

A  permanent  redness  of  the  skin,  combined  with  an  often 
almost  insufferable  itching,  constitutes  the  lowest  stage  of 
freezing.  The  next  stage  is  presented  by  chilblains,  i.  e., 
sharply-circumscribed,  roundish  swellings,  of  a  bluish-red 
color  and  a  flabby  consistency,  which  are  also  associated  with 
an  annoying  sensation  of  itching,  or  even  of  violent  pain. 

A  weakened  power  of  resistance,  a  certain  sacrifice  of  the 
elasticity  and  contractility  of  all  the  firm  cutaneous  parts,  and 
especially  a  diminution  in  blood  pressure,  are  present  in 
chilblains  and  in  the  hypersemia  due  to  cold.  This  lack  of 
resistance  is  conspicuously  shown  toward  irritations  from  cold, 
which,  although  slight,  and  of  short  duration,  produce  a  dis- 
proportionate exhaustion,  and  at  the  same  time  an  extensive 
and  permanent  dilatation  of  the  blood  vessels  and  swelling  of 
the  parenchyma.  The  frozen  members  usually  remain  in  a 
quiescent  state  during  the  summer,  but  at  the  first  approach 
of  cold  weather,  begin  to  swell  and  be  painful.  The  extreme 
stage  of  freezing  constitutes  necrosis.  The  frosted  parts  are 
removed  by  inflammation  and  suppuration,  if  this  result 
has  not  been  previously  attained  by  timely  amputation. 


196  GENERAL   PATHOLOGY. 

Diseases  of  Exposure. 

A  particular  kind  of  local  withdrawal  of  heat  furnishes 
the  raison  d'etre  for  what  are  called  diseases  of  exposure. 
These  include  hypersemic,  sub-inflammatory,  and  inflamma- 
tory conditions  which  are  marked  by  "  regional "  occurrence 
and  by  a  "  periodic-typical "  course,  the  latter  being,  of  course 
variously  obscured  by  irregularities,  complications,  and  quan- 
titative excess  of  individual  symptoms.  The  connection  be- 
tween these  diseases  and  cold  is  established  by  the  nervous 
system.  A  molecular  change  in  the  sensitive  nerve-ends  of 
the  region  affected  by  cold  is  transmitted  (in  a  manner  as  yet 
unknown)  to  the  central  nervous  system,  and  thence  to 
the  seat  of  disease,  where  it  appears  in  the  shape  of  an  altera- 
tion of  the  vascular  wall  with  the  results  already  enumerated. 

If  we  desire  to  observe  the  process  of  taking  cold  step  by 
step,  we  must  consider  the  condition  of  the  skin  at  the  time 
of  taking  cold  as  the  starting  point. 

We  all  know  that  we  take  cold  most  easily  after  being  over- 
heated. When  the  temperature  of  the  blood  has  been  raised 
by  violent  and  continued  muscular  exertion,  like  running, 
marching,  dancing,  calisthenics,  and  the  blood,  in  order  to 
cool  more  rapidly,  seeks  the  surface  of  the  body  and  produces 
a  strong  hypersemia  of  the  skin,  there  is  immediate  danger  of 
taking  cold.  The  skin  is  then  more  irritable  and  much  more 
sensitive  to  cold  than  normally.  This  is  equally  true  of  those 
superficial  parts  which,  from  other  causes,  possess  an  abnor- 
mally large  blood  supply,  secrete  much  sweat,  etc.,  i.  e.,  the  parts 
which  have  been  rendered  susceptible  by  an  excess  of  clothing. 

Diseases  resulting  from  exposure  are  most  frequent  in  the 
temperate  zone.  They  are  of  much  rarer  occurrence  both 
among  the  naked  or  half-clothed  natives  of  the  torrid  zone, 
and  among  the  Esquimaux  who  wear  a  uniform  covering  of 
skins  throughout  the  year.  We  know  of  no  other  way  to 
attach  our  clothing  than  upon  our  shoulders  and  around  our 
hips.  At  these  points,  consequently,  there  is  an  unavoidable 
accumulation  of  thick  and  heavy  folds,  so  that  the  lumbar 
and  deltoid  regions  are  most  warmly  and  constantly  covered. 
The  temperature  is  always  higher  here  than  that  of  the  skin, 
perspiration  is  more  frequent  and  profuse,  and  as  there  is 
usually  admirable  protection  against  cold,  there  is,  in  con- 
sequence, unusual  susceptibility  to  the  same.  As  with  the 
regions  of  the  shoulder  and  hip,  so  with  the  feet,  which  we 


TRAUMATIC    DISEASES.  197 

shield  from  wet  and  injuries  by  thick  and  impermeable  leather 
soles.  The  same  applies  in  a  measure  to  all  portions  of  the 
body  which  we  are  in  the  habit  of  covering.  They  are  more 
or  less  over-sensitive  to  cold. 

Seeking  to  locate  this  heightened  susceptibility  to  cold,  and 
addressing  ourselves  first  only  to  those  structural  parts  which 
exhibit  most  plainly  the  phenomena  of  irritability,  viz. — the 
nerves  and  muscles — we  find,  in  the  muscles,  a  disproportion- 
ately strong  contraction  answering  to  a  moderate  withdrawal 
of  heat ;  in  the  sensitive  nerve  ends  a  strong  and  rapid  ad- 
vance of  molecular  change,  which,  when  presented  to  our  con- 
sciousness as  a  sensation  of  chilliness,  demands  that  we  should 
exert  ourselves  to  prevent  the  local  loss  of  heat.  This  can 
only  be  a  physical  change  in  the  nerve  ends,  a  transition  of 
the  molecule  from  a  strong  to  a  weak  thermal  activity,  pre- 
paratory to  complete  rigidity. 

A  moderate  sensation  of  cold  is,  however,  unfortunately,  so 
pleasant  that  even  sensible  people  require  many  severe  lessons 
before  they  learn  to  adopt  the  proper  measures  against  taking 
cold,  preferring  to  entirely  ignore  cold  as  a  cause  of  disease, 
rather  than  submit  to  the  requirements  of  our  trying  climate. 
It  is  remarkable  that  in  sleep  the  central  nervous  system 
rarely,  if  ever,  disregards  the  warning  of  the  cutaneous  nerves, 
when  threatened  by  cold,  or  fails  to  acknowledge  them  by 
suitable  reflex  activity.  Uncovered  arms  and  knees  are 
promptly  thrust  under  cover,  as  may  be  seen  nightly  with 
sleeping  children.  In  this  respect  we  are  more  reasonable  in 
sleep  than  when  awake,  when  we  cannot  deny  ourselves  harm- 
ful enjoyment.  There  are,  of  course,  besides  the  pleasurable 
sensation  of  cold,  other  causes  which  lead  us  to  disregard  the 
danger  from  exposure.  Such  are,  great  mental  pre-occupation, 
or  a  force  majeure  which  prevents  the  perception  or  avoidance 
of  the  danger. 

The  best  means  for  averting  cold  is,  without  doubt,  the 
proper  protection  of  those  parts  of  the  body  which  are  ex- 
posed to  its  influence.  The  precautions  used  against  freezing 
are  found  to  be  equally  efficacious  here,  namely,  the  mechanical 
treatment  of  rubbing,  kneading,  massage,  etc.  By  thus  es- 
tablishing "  counter-irritation,"  i.  e.,  an  irritation-hypersemia, 
the  effects  produced  by  the  loss  of  heat  are  neutralized  by  the 
abundant  addition  of  warm  blood. 

If  the  withdrawal  of  heat  is  not  checked,  there  is  danger 


198  GENERAL  PATHOLOGY. 

that  the  contraction  of  the  cutaneous  blood  vessels,  and  the 
relative  exclusion  of  warm  blood  attendant  thereon,  should 
co-operate  with  the  external  withdrawal  of  heat  to  produce  a 
numbed  condition  of  the  terminal  nerves.  This  I  consider 
the  immediate  provocation  to  the  diseases  produced  by  cold. 
The  subject  includes  much  that  is  peculiar.  The  withdrawal 
of  heat  is,  as  a  rule,  neither  powerful  nor  of  profound  effect.  An 
almost  imperceptible  breeze  will  soonest  give  cold.  The  most 
superficial  cutaneous  layers,  or,  indeed,  only  the  nerve  ends, 
appear  alone  to  be  acted  upon.  The  sensitive  nerve-ends  of 
the  papillary  layer  terminate,  as  we  know,  in  different  papillae 
from  those  of  the  terminal  capillary  vessels,  so  that  the  isolated 
action  of  cold  upon  the  tactile  corpuscles  is  not  improbable. 
The  epithelial  nerves  are  also  to  be  considered.  Hence,  after 
taking  cold,  there  is  a  sense  of  numbness  and  formication  in 
the  skin,  apart  from  the  slight  and  almost  regularly-recurring 
chill,  which  proceeds  from  the  affected  part.  But  the  percep- 
tion of  these  finer  grades  of  sensitiveness  which  mark  a  cold, 
require  so  attentive  a  central  nervous  system  that  the  gener- 
ality of  patients  "  do  not  know  how  they  caught  cold." 

Deserving  of  special  notice  is  the  danger  to  cold  arising 
from  the  fact  that  the  typically  sensitive  portions  of  the  skin 
are  liable  to  perspire  easily,  so  that  the  clothing  becomes  satu- 
rated with  perspiration.  Wet  clothes  are  good  conductors  of 
heat,  consequently,  when  the  outer  air  reaches  them  and  they 
become  cold,  they  extract  the  heat  from  the  surface  of  the 
skin  in  so  marked  a  degree  that  only  the  most  violent  physical 
exercise  can  counteract  their  effect.  And  when,  besides  the 
inner  moisture  and  the  outer  cold,  the  body  is  subjected  to 
soaking  rain,  we  may  with  great  likelihood  look  forward  to  a 
fit  of  sickness. 

We  must  reluctantly  concede  that  there  still  exists  a  gap 
in  our  exact  knowledge  of  the  relations  of  exposure  to  the 
diseases  resulting  from  exposure.  Although  the  fact  of  the 
connection  admits  of  no  doubt,  it  is,  notwithstanding,  difficult 
of  definition.  In  the  foregoing  discussion  we  have  found  little 
which  is  characteristic  of  the  process  of  taking  cold  above 
any  other  local  withdrawal  of  heat.  I  have  tried  to  establish 
the  probability  of  the  isolated  action  of  cold  upon  the  sensi- 
tive nerve-ends,  the  numbness  of  the  tactile  corpuscles,  or 
even  of  the  epithelial  nerves,  as  characteristics,  of  the  process 
of  taking  cold.  I  desire  to  emphasize  the  consequent  discord 


TRAUMATIC   DISEASES.  199 

in  the  centripetal  irritations,  which,  proceeding  from  the  skin, 
as  well  as  from  the  other  bodily  organs,  are  incessantly  com- 
municated to  the  central  nervous  system.  These  irritations 
determine  the  measure  and  distribution  of  the  continuous 
active  participation  of  the  central  nervous  system,  which  is 
consummated  within  the  tonus  of  the  vascular  and  bodily 
muscular  structure.  This  might  point  to  a  local  "  attack  of 
irritation,"  which  would  induce  a  local  "  inhibition  of  mus- 
cular innervation."  The  direct  paralysis  of  individual  or 
groups  of  muscles,  from  cold,  would  chiefly  support  such  a 
conclusion.  I  doubt,  however,  whether  that  painful  affection, 
usually  called  muscular  rheumatism,  can  be  ranked  under  this 
head.  At  any  rate,  it  exhibits  a  combination  of  vaso-motor 
and  neuro-inuscular  paralysis.  In  most  cases,  the  vaso-motor 
paralysis  constitutes  the  starting  point  of  the  entire  disease 
resulting  from  exposure. 

The  regions  of  the  arterial  vascular  system  are  continuous 
with  the  organs  of  the  body,  but  in  especial  are  they 
intimately  connected  with  the  mucous  and  other  membranes 
which  are  organically  circumscribed  and  simple  in  their  func- 
tions. Local  hypersemia,  brought  about  not  so  much  by  a  vaso- 
motor  inhibition  as  by  a  kind  of  reflex  paralysis  of  the  central 
source  of  power,  is  what  generates  the  process  of  taking  cold. 
This  hypersemia  attacks  the  heart,  joints,  nasal  cavity,  isthmus 
of  the  fauces,  pharynx,  larynx,  trachea,  bronchi,  small  intes- 
tines, bladder,  lungs,  pleura,  eyes,  ears,  etc.  It  is  associated 
with  a  certain  inclination  to  concentrate  the  blood  supply  in 
the  direction  of  free  surfaces.  This  localization  is  aided  by 
the  weight  of  the  blood,  which  operates  in  inflammations  of 
the  lungs.  There  are  other  irritants  which  tend  partly  to 
localize,  partly  to  increase  the  rheumatic  hypersemia.  Among 
these  we  must  enumerate  physiological  exertion,  which  makes 
some  organs  especially  sensitive  at  the  moment  of  exposure  to- 
cold.  We  know  that  articular  rheumatism  is  often  the  result 
of  violent  and  prolonged  bodily  exertion,  over-heating  in 
dancing,  for  example,  which  likewise  leads  to  rheumatic  endo-, 
myo-  and  pericarditis.  People  who  have  suffered  much  from 
diseases  resulting  from  exposure  generally  possess  a  locus 
minoris  resistentice.  The  mucous  membrane  of  the  respiratory 
tract,  especially  the  nasal  mucous  membrane,  is  most  frequently 
attacked. 

There  still  remains  an  important  point  for  pathology  to 


200  GENERAL   PATHOLOGY. 

ascertain,  viz.,  to  what  circumstance  is  it  due  that  these 
diseases  are  not  content  to  establish  an  hypersemia,  however 
strong  it  may  be,  but  proceed  to  inflammation  and  exudation. 
It  is  possible  that  there  are  two  factors  at  work. 

First  of  all,  we  have  not  a  simple  fluxion,  but  a  neuro- 
paralytic  filling  of  the  blood  vessels,  which  is  aided  by  a  per- 
manent change  in  the  nervous  system.  But  so  soon  as  any, 
even  an  arterial  hypersemia  assumes  a  more  permanent 
character,  the  blood  which  fills  the  hypersemic  part  develops 
by  its  own  gravity  a  gradual  retardation  of  the  circulation, 
with  increased  lateral  pressure.  This  is  conspicuous  in  pro- 
portion to  the  dilatability  of  the  capillary  walls  of  the  part 
and  their  nearness  to  the  surface,  it  being  less  noticeable  in 
those  whose  situation  is  deeper.  Thus  we  have  a  partial  ex- 
planation of  the  already-mentioned  tendency  of  rheumatic 
hypersemia  to  concentrate  on  the  surface,  and  to  cause  the 
filtration  of  the  liquid  constituents  of  the  blood  from  the 
peripheral  capillaries.  Just  at  this  point  the  second  inflam- 
matory factor  exerts  a  powerful  influence.  This  factor  is  the 
implantation  of  lower  organisms.  These  are  not  usually 
capable  of  withstanding  the  normal  forces  at  work  in  the  pro- 
duction of  the  animal  tissue  change  which  are  prejudicial 
to  their  welfare;  but,  when  once  introduced  into  a  region 
where  a  sluggish  interchange  of  blood  is  followed  by  a  still 
more  sluggish  tissue  interchange,  they  find  a  congenial  soil  in 
which  to  settle  and  proliferate.  They  are  not  necessarily 
specific  pathogenetic  microphytes.  As  a  rule,  they  are  merely 
the  usual  fungi  of  decomposition,  which  are  taken  in  with  the 
food  and  respiration,  and  are  in  part  deposited  upon  the 
mucous  membrane,  and  in  part  carried  by  the  blood  to  the 
different  vascular  regions  of  the  bodv,  reaching  thereby  the 
parts  affected  with  rheumatic  hypersemia.  There  can  be  no 
doubt  but  that  the  local  process  assumes  thereby  an  acutely 
inflammatory,  purulent,  or  even  putrid  character.  In  its 
newly-acquired  character,  metastates  of  the  primary  inflam- 
mation are  possible.  But  we  must  constantly  bear  in  mind 
that  the  implantation  of  microphytes  is  in  these  instances  a 
secondary  matter,  which  would  not  justify  us  in  classifying 
rheumatism  as  an  infectious  disease. 

As  even  the  most  hasty  portrayal  of  all  diseases  resulting 
from  cold  would  exceed  the  limits  of  this  work,  I  must  con- 
tent myself  with  a  brief  summary  of  the  same. 


PARASITIC    AND    INFECTIOUS    DISEASES.  201 

I.  Local  inflammations  of  the  mucous  membranes,  to  which 
are  applied  the  terms  simple  and  catarrhal.     The  most  com- 
mon are:  catarrh,  coryza,  catarrhal  tracheo-bronchitis  and 
catarrhal  laryngitis.     Rarer  are  catarrhs  of  the  conjunctiva 
and  the  external  auditory  meatus.     Catarrhal  tonsillitis  and 
pharyngitis  are  very  frequent ;  they  are  often  associated  with 
catarrh  of  the  Eustachian  tubes. 

II.  Inflammations   of   glandular    organs,   principally  the 
sporadic  form  of  croupous  pneumonia  and  acute  nephritis. 

III.  Inflammations  of  the  motory  apparatus ;  arthritis  and 
rheumatic  myositis. 

IV.  Inflammations  of  the  heart ;  endocarditis,  myocarditis, 
rheumatic  pericarditis. 

V.  Non-specific  sero-fibrinous  inflammations  of  the  pleura. 

(d)    ELECTRICAL   TRAUMA. 

In  the  preceding  traumata  we  have  been  able  to  name 
certain  contrivances  by  which  the  organism  has  been  in  a 
measure  ingeniously  protected.  Against  electrical  traumata 
there  is  no  such  protection.  On  the  contrary,  the  close  con- 
nection between  electric  movement  and  the  excited  state  of 
the  active  nerves  prepares  an  easy  entrance  for  electricity  into 
the  body.  If  electrical  manifestations  were  more  frequent  in 
the  natural  world,  we  should  more  frequently  meet  with  dis- 
eased conditions  attributable  to  the  same.  This  is,  however, 
not  the  case,  for,  with  the  exception  of  lightning,  no  electricity 
is  dangerous,  although  much  has  been  said,  especially  among 
the  laity,  about  magnetism  as  a  cause  of  disease.  Electro- 
magnetism  has  become  a  valuable  factor  in  equalizing  patho- 
logical disturbances  in  the  nervous  system  and  thereby  in  all 
the  organs  of  the  body.  Both  the  constant  and  interrupted 
electrical  currents  are  employed,  chiefly  in  order  to  preserve 
the  excitability  of  the  nerves  and  exercise  their  terminal 
apparatus,  by  assisting  the  impaired  or  obstructed  innerva- 
tion,  until  the  diseased  obstruction  shall  be  removed. 

II.  PARASITIC  AND  INFECTIOUS  DISEASES. 

The  diseases  resulting  from  mechanical  injuries,  from  heat 
and  cold,  and  from  chemical  injuries,  must  be  distinguished 
from  those  which  are  communicated  to  us  by  our  fellow- 
creatures,  just   as   inanimate   nature  is   distinguished  from 
14 


202  GENERAL   PATHOLOGY. 

animate  nature.  By  the  latter  I  do  not  allude  to  battle  and 
bloodshed,  nor  to  the  attacks  of  wild  beasts  to  which  men  are 
sometimes  exposed  and  which  partake  more  of  the  nature  of 
mechanico-chemical  traumata,  but  of  the  fatal  operation  of 
those  beings  which  have  chosen  the  human  body  for  habita- 
tion and  subsistence,  and  lead  in  and  upon  man — as  it  is  ex- 
pressed— a  parasitic  existence.  There  are  many  animals  and 
plants  whose  nature  forces  them  to  this  mode  of  subsistence ; 
others,  again,  which  only  feed  upon  the  juices  of  the  human 
body  in  the  absence  of  other  food. 

All  these  plants  and  animals  approach  us  from  without. 
They  fly,  jump  and  crawl  upon  us,  are  inhaled  with  the  air, 
acquired  from  clothing  and  utensils,  and  are  rubbed  in  and 
inoculated  in  a  thousand  and  one  different  ways.  Any  free 
surface  of  the  body  affords  them  a  foothold.  Often  it  is  the 
skin  or  the  mucous  membranes ;  in  many  cases  it  is  the  inner 
surface  of  the  respiratory  apparatus  or  that  of  the  stomach 
and  intestines. 

As  soon  as  a  deposition  (invasion)  is  effected,  the  peculiar 
(specific)  life  of  the  invader  asserts  itself.  The  neighboring 
cells  and  juices  must  furnish  nourishment,  and  are  either  de- 
composed, dissolved,  or  consumed  as  a  whole.  The  body  re- 
acts, and  inflammations  of  various  kinds  set  in.  But  the 
affection  remains  purely  external,  so  long  as  the  parasites  con- 
fine themselves  to  the  surface,  so  long  as  they  remain  epizoa 
and  epiphyta,  in  the  restricted  sense  of  the  terms. 

It  is  quite  different,  however,  when  they  or  their  progeny 
forsake  the  seat  of  their  original  deposition,  in  order  to  pene- 
trate into  and  infect  the  body.  The  smaller  animal  parasites, 
like  the  trichinae,  effect  this  by  the  vigorous  activity  of  their 
movements,  especially  when  their  bodily  structure  is  such  as 
to  favor  their  entrance  into  the  body.  The  vegetable  parasites, 
being  generally  deprived  of  the  power  of  voluntary  motion, 
depend  primarily  upon  their  small  size  for  their  chances  of 
infection.  Fungi  of  the  size  of  the  common  mould  varieties 
send  out  their  mycelia  as  far  as  to  the  deepest  layers  of  the 
loose  epithelium,  but  are  very  rarely  able  to  effect  an  en- 
trance into  the  bodily  parenchyma  proper.  Germ-fungi  of 
the  size  of  the  torula  cerevisice  and  the  tnycoderma  aceti  are 
also  unable  to  enter.  Only  the  most  minute — the  cleft-fungi 
(Schizomycetce) — are  small  enough  to  penetrate  into  the  blood 
and  lymphatic  vessels,  through  the  interstices  of  the  bodily 


PARASITIC   AND   INFECTIOUS   DISEASES.  203 

texture.  Their  smallness  often  borders  upon  the  imper- 
ceptible. 

The  cleft-fungi  are,  notwithstanding,  not  invariably  devoid 
of  individual  motion.  The  earliest  known  and  most  frequent 
variety  of  decomposition-bacilli  were  named  vibrios  (quiver- 
ing animalcules),  because  the  tiny  bacilli,  moving  rapidly  to 
and  fro  in  the  putrescent  fluid,  executed  rotary  and  forward 
movements,  which,  to  the  first  observers,  resembled  the  uneasy 
ferreting  movements  of  the  infusorial  animalcules.  In  stagnant 
water  we  perceive  microbes  darting  with  lightning  speed 
across  the  line  of  vision,  and  upon  evaporating  and  coloring 
the  sediment  with  methyl-violet,  we  find  the  microbes  to  be 
provided  with  short,  thread-like  feelers,  which  serve  them,  in 
their  rapid  passage,  as  a  "  screw."  It  is  possible  that  other 
schizomycetes  and  their  germs  possess  a  similar  mobility, 
which  facilitates  their  entrance  into  the  bodily  parenchyma. 
When  the  invaders  have  once  reached  the  blood,  no  further 
assistance  is  required  to  diffuse  them  with  it  throughout  the 
body  arid  complete  the  work  of  infection. 

With  the  achievement  of  this  latter  step,  the  fight  for  life 
between  man  and  the  parasites  is  transferred  from  the  surface 
to  the  interior  of  the  body.  We  feel  little  concern  in  regard 
to  the  epizoa  and  epiphyta,  knowing  that  at  the  worst  they 
can  be  removed  with  comparative  ease  and  safety,  and  ren- 
dered innocuous,  but  with  the  entozoa  and  entophyta  it  is  a 
more  serious  matter. 

The  entozoa,  it  is  true,  upon  migrating  into  the  blood,  are 
easily  observed.  Some  of  them  (Filaria  sanguinis  and  Dis- 
tomum  hsernatobium)  choose  the  blood  for  a  permanent 
abiding  place.  Others  use  it  as  a  convenient  channel  through 
which  to  gain  a  more  congenial  locality  for  further  develop- 
ment. Such,  principally,  are  the  tsenia  embryos,  which 
develop  into  Echinococcus  hepatis  or  Cysticercus  cellulosse. 
The  trichinae  embryos  appear  to  reach  the  muscles,  not  by 
way  of  the  blood,  but  directly  through  the  tissues.  All  these 
entozoa  produce  at  the  point  of  implantation  inflammatory 
processes,  which,  although  in  themselves  of  a  simple  non- 
specific sort,  may,  upon  occasion,  give  rise  to  serious  lesions 
of  a  local  and  general  nature,  and  even  terminate  in 
death. 

Of  a  much  more  complicated  character  are  the  results  due 
to  the  immigration  of  cleft-fungi,  viz.,  Infectious  diseases. 


204  GENERAL    PATHOLOGY. 

The  very  entrance  of  these  unwelcome  guests  is  liable  to 
inflict  severe  injury  upon  the  channels  of  entrance.  Here  we 
find  surface  colonies,  where  the  colonists  multiply  to  many 
times  their  original  number,  before  the  first  assault  is  directed 
towards  the  interior.  This  is  the  signal  for  the  outbreak  of 
inflammations  at  the  first  faint  attack,  and  in  local  lymph 
paths  and  glands — inflammations  which  bear  a  markedly 
"  specific  "  imprint. 

The  character  of  a  specific  inflammation  has  been  considered 
in  the  general  division  of  this  work.  It  includes  hypersemia, 
exudation,  but  chiefly  inflammatory  irritation,  regulated  and 
controlled  by  a  living  virus,  which  declares  its  species  by 
many  well-defined,  often -repeated,  and  obvious  characteristics. 

The  majority  of  the  "  invading  "  specific  inflammations  are 
marked  by  the  intervention  of  some  sort  of  tissue  necrosis, 
either  as  in  diphtheria,  as  a  preliminary  to  further  changes, 
or,  as  in  tuberculosis,  where  the  completed  products  of  inflam- 
mation undergo  necrosis.  This  tissue  necrosis  is  the  exclusive 
product  of  the  microphytes.  It  reveals,  so  to  speak,  the  ten- 
dency of  their  vital  activity  and  gives  us  a  clue  to  other 
specific  inflammatory  phenomena.  The  slight  inclination  of 
certain  tuberculous,  syphilitic,  leprous  and  other  products  of 
inflammation  towards  organization,  their  arrest  as  partly 
formed  granulation  tissue,  and  also  the  striking  individual 
formation  of  separate  cells  into  an  "  epithelioid  "  structure, — 
all  may  be  chargeable  to  the  parasites,  which  weaken  the  vital 
energy  and  the  relations  to  the  organism  at  large.  The  recent 
discovery  of  tubercle-  and  lepra-bacilli  in  these  very 
epithelioid  cells  appears  to  confirm  this  hypothesis.  So  much 
is  certain,  that  these  cells  invariably  represent  the  acme  of 
the  specific  process  and  are,  if  necrosis  ensue,  most  fittingly 
psrpetuated  in  the  same. 

Just  beyond  these  cells,  or,  in  their  absence,  immediately 
adjoining  the  necrotic  process,  there  arises  a  qualitative, 
non-specific,  reactive  inflammation.  This  is  not  rarely  of  a 
salutary  character,  if  it  succeeds  in  disarming  the  poisonous 
visitors  by  encapsulation,  or  throws  them  off  by  suppuration 
together  with  the  specific  products  of  inflammation,  thus  pro- 
tecting the  threatened  body  from  the  general  infection. 

If  the  reception  of  the  microphytes  becomes  an  accomplished 
fact,  we  may  expect,  first  of  all,  a  condition  of  fever,  which, 
according  to  previous  definitions  (  Vide  Fever  and  its  Cause), 


PARASITIC   AND   INFECTIOUS   DISEASES.  205 

we  shall  understand  either  as  a  direct,  fermentative  increase  of 
temperature,  or  as  one  attributable  to  the  irritated  nervous  sys- 
tem. To  attain  this  end,  a  large  amount  of  active  virus  is,  of 
course,  required.  Consequently,  when  there  has  been  no 
previous  proliferation  of  the  parasites  at  the  point  of  the  first 
superficial  implantation,  when  only  one,  or  at  most  a  limited 
number  of  the  diseased  germs  have  passed  directly  into  the 
blood,  a  certain  space  of  time  must  necessarily  elapse  before 
the  few  become,  by  continued  division,  sufficiently  prolific  to 
effect  an  irritation  of  the  central  nervous  system,  or,  to 
establish  zymotic  processes  of  any  magnitude.  This  period  of 
"  proliferation  of  the  schizophytes  in  the  blood  "  is  called  the 
stage  of  incubation.  It  is  not  probable  that  the  proliferation 
occurs  in  the  blood  while  in  motion.  The  swelling  of  the 
spleen  in  most  infectious  diseases  intimates,  on  the  contrary, 
that  the  growth  is  especially  successful  there,  where  the  blood 
flow  is  retarded  almost  to  stasis.  From  this  or  some  equiva- 
lent focus,  there  ensues  a  flooding  of  the  entire  body  with  the 
microphytes,  which  being  single,  continuous  or  repeated, 
determines  whether  the  infectious  disease  in  question  shall  be 
accompanied  by  single,  continuous,  or  repeated  paroxysms  of 
fever. 

Hereupon  comes  a  new  localization  of  the  poison.  The 
cleft-fungi  are  undoubtedly  carried  past  all  the  organs  of  the 
body.  In  a  treatise  *  which  has  failed  to  attract  attention  I 
explained  why  the  arteries,  and,  particularly,  the  arterial 
capillaries,  are  likely  to  be  first  chosen  by  the  wandering 
cleft-fungi  as  their  new  point  of  settlement  (Vide  specific 
inflammation,  embolism,  etc.,  General  Part).  This  is  not, 
however,  a  satisfactory  explanation  of  the  phenomena  of 
localization.  We  are  reminded  of  the  intoxications  when 
we  see  that  certain  fungi  select  certain  organs.  Since  the 
natural  organs  of  secretion,  the  kidneys,  intestinal  canal, 
skin  or  lungs  are  affected,  it  leads  one  to  think  that  it  is 
an  attempt  on  the  part  of  these  organs  to  reject  the  unusual 
materies  peccans.  It  would  doubtless  be  more  correct  to 
infer  a  co-operation  of  the  local  vascular  apparatus  with  the 
conditions  of  growth  imposed  by  the  chemical  contexture  of 
the  parenchyma,  and  from  this  standpoint  alone  to  judge 
of  the  localization  of  diseases  of  the  secretory  organs.  For 

*  On  Vasculitis  Specifica,  a  contribution  in  honor  of  the  Three 
Hundredth  Anniversary  of  the  University  of  Wurzburg. — Leipzig. 


206  GENERAL    PATHOLOGY. 

experience  teaches  us  that  this  attempt  at  secretion  is  of  very 
little  account,  as  the  body  must  either  dispose  of  these  ento- 
parasites  by  consuming,  i.  e.,  oxydizing  them,  or  be  consumed 
by  them  in  return. 

The  specific  processes  of  inflammation  evoked  by  these 
secondary  localizations  are  most  manifold  and  characteristic. 
They  proceed,  as  already  stated,  invariably  from  the  blood 
vessels,  and  with  great  partiality  from  the  terminal  arteries, 
around  which  the  inflammatory  products  are  first  deposited 
(Specific  Endo-  and  Peri-Vasculitis).  From  here  they  ad- 
vance into  the  parenchyma,  whereupon  the  same  metamor- 
phoses take  place  which  we  have  already  studied  in  the 
invading  inflammations.  We  meet  with  the  same  tubercle 
cells  in  the  primary  seats  of  inflammation  in  the  phthisical 
lung,  as  in  the  miliary  tubercles  which  usurp  the  small 
arterial  ends  in  resorption  tuberculosis.  As  in  tuberculosis, 
so  we  find  in  all  other  infectious  diseases.  Nothing  is  more 
calculated  to  demonstrate  the  unity  of  these  diseases  under  a 
uniform  pathological  irritation  than  this  typical  recurrence  of 
the  specific  products  of  disease  at  all  the  centres  of  localization. 

I  have  not  the  requisite  space  to  describe  here  the  further 
changes  undergone  by  the  microphytes  after  their  deposition 
in  the  blood.  This  pertains  to  pathological  anatomy  and 
histology,  to  which  branches  I  must  repeatedly  refer  the 
reader.  I  shall,  however,  take  occasion  to  return  to  the  sub- 
ject of  the  abode  and  diffusion  of  the  pathogenetic  schizo- 
phytes  outside  of  the  human  body,  and  of  the  ways  and 
means  in  which  infection  may  be  communicated. 

(a)   ANIMAL   PARASITES. 

Arthropoda, 

Acarus  Scabiei  (Itch  mite).  Body  rounded,  0.2  to  0.4  mm. 
in  diameter,  possessing  long  bristles,  and  short  spines  pointing 
backward  ;  eight  legs,  short  and  conical,  four  of  which  project 
forward,  and  are  provided  with  stalked  suckers.  Between  the 
latter,  a  short  head,  with  apparatus  for  biting  and  sucking. 

It  inhabits  canals  made  by  itself,  in  the  upper  layers  of 
the  epidermis,  whence  it  occasionally  descends  into  the  corium 
in  search  of  food.  The  fema'le  deposits  in  these  canals,  eggs, 
from  which  the  six-legged  larvse  are  very  rapidly  developed. 
These  wander  over  the  cuticle  seeking  a  home  of  their  own, 


PARASITIC   AND   INFECTIOUS   DISEASES.  207 

until,  after  repeatedly  casting  their  skin,  they  become  sexual 
animals. 

The  first  deposition  of  the  acarus  is  generally  made  in  the 
thin  skin  between  the  fingers  and  toes,  as  well  as  on  the  flexor 
surfaces  of  the  arms  and  legs.  Later,  the  whole  skin  may 
become  involved.  An  annoying  itching  causes  severe  scratch- 
ing, which  results  in  inflammation  of  the  corium.  Red 
papules  and  watery  vesicles  form,  and  these,  after  being 
scratched  open,  are  covered  again  with  a  brownish  scab.  The 
entire  skin  becomes,  finally,  reddened  and  thickened,  and  an 
abundant  epidermal  exfoliation  takes  place. 

Acarus  foliiculorum  (Comedone  mite).  Slender  body,  0.2 
mm.  in  length,  four  pair  of  short  feet  on  the  anterior  portion 
of  the  body.  Harmless  tenants  of  sebaceous  glands  (Come- 
dones), especially  of  the  nose. 

Pediculis  capitis,  p.  pubis,  p.  vestimentorum  (head-louse, 
crab-louse,  body-louse) ;  cimex  lectularius  (beet-bug) ;  and 
pulex  irritans  (common  flea),  need  only  be  mentioned. 

Pentastomum  denticulatum,  a  still  unexplained  arachnid, 
found  now  and  then,  in.  a  calcified  condition,  in  the  liver. 

Nematodes. 

Parasitic  nematodes,  like  all  round  worms,  have  a  long, 
cylindrical,  unarticulated  body,  which  resembles  a  contractile 
tube,  within  which  are  situated  the  digestive  tract  and  genital 
organs,  which  are  furnished  with  a  mouth,  anus,  and  also  a 
sexual  opening. 

Ascaris  lumbricoides.  The  male  is  about  25  cm.  long,  the 
female,  40  cm.  Bodies  round,  like  earth  worms,  but  yellowish- 
white  in  color.  The  ovaries  contain  numerous  rather  long 
and  very  thick-shelled  ova,  50  to  60  ft.  in  diameter.  The 
latter  are  found  in  the  faeces  of  man,  but  their  development  is 
obscure,  as  is  also  the  manner  in  which  the  young  ascarides 
find  a  new  home. 

The  round  worm  lives  in  the  small  intestines,  but  rarely 
occasions  any  serious  disturbances,  except,  perhaps,  when  it 
travels  through  the  ductus  choledochus  into  the  liver,  and 
produces  abscesses. 

Oxyuris  vermicularis  (Thread  worm).  Female,  10  mm.  in 
length ;  male,  4  mm.  Long  and  thin,  like  threads.  Eggs, 
oblong,  flattened  on  one  side.  Thousands  of  them  exist  in 
the  intestines,  whence  their  nocturnal  journeyings  often 


208  GENERAL   PATHOLOGY. 

bring  them  to  the  verge  of  the  anus.  The  excessive  irritation 
thus  produced  disturbs  the  sleep  of  children  (the  oxyuris  is 
rarely  found  in  adults),  and  leads  to  abuse  of  the  genital 
organs  and  to  masturbation. 

Trichocephalus  dispar.  Female,  4-5  cm.  long;  has  a 
straight,  involuted,  thick  body,  containing  the  ova,  which  are 
oblong  and  provided,  above  and  below,  with  small  nodules. 
The  male  is  spiral.  Both  male  and  female  have  flagellated, 
attenuated,  anterior  extremities.  These  harmless  parasites 
are  sparsely  distributed  throughout  the  small  intestines. 

Strongylus  duodenalis  (Dochmius,  Anchylostomum).  Body 
1  to  1.5  cm.  in  length,  round,  expanded  in  the  centre,  head 
distinct  and  furnished  with  four  strong  teeth.  The  male 
terminates  posteriorly  in  a  funnel-shaped,  loose  pouch  ;  the 
female  is  sharply  pointed.  In  the  tropics  it  is  a  frequent  in- 
habitant of  the  duodenum.  It  bites  into  the  mucous  mem- 
brane, sucks  itself  full  of  blood,  and,  like  the  leech,  leaves  a 
bleeding  and  wounded  spot  behind.  The  Egyptian  chlorosis 
and  the  much  discussed  beriberi  disease  of  the  Sunda  Islands 
appear  to  be  due  to  this  worm. 

Eustrongylus  gigas.  1  m.  long  and  12  mm.  in  diameter ; 
blood-red.  Observed  in  the  pelvis  of  the  kidney.  More 
common  in  animals  than  in  man. 

Anguillula  stercoralis.  Thread-like  worms  1  mm.  in  length. 
Myriads  of  them  live  in  the  large  and  small  intestines, 
occasioning  diarrhoea,  wasting  anaemia,  and  stubborn  stoma- 
titis. Cochin  China. 

Trichina  spiralis.  The  smallest  but  most  dangerous  of 
European  round  worms.  Male  attains  at  most  1.5  mm.  in 
length ;  female  3  mm.  Owing  to  their  smallness  and  trans- 
parency, hard  to  distinguish  with  the  naked  eye.  The  body 
is  round,  pointed  anteriorly,  truncated  posteriorly.  Adjoining 
the  oral  cavity  is  the  beginning  of  the  intestinal  tract,  which  is 
provided  with  a  series  of  large  gland-cells.  In  the  female, 
the  highly-developed  genital  apparatus  occupies  the  re- 
maining space  in  the  body.  It  not  only  contains  eggs  in 
all  stages  of  development,  but  also  the  matured  embryos, 
which  are  discharged  from  the  genital  pores,  situated  in  the 
centre  of  the  body.  A  single  female  can  mature  as  many  as 
400  young.  The  process  takes  place  in  the  small  intestines  of 
the  pig,  mouse,  and,  unfortunately,  also  of  man.  The  trichina 
embryos  advance  from  the  intestinal  lumen  through  the 


PARASITIC   AND   INFECTIOUS   DISEASES.  209 

intestinal  wall,  and  between  the  layers  of  the  mesentery 
into  the  connective  tissue  of  the  body,  and  thence  into  the 
muscular  structures,  where  they  temporarily  reside.  The 
muscles  along  the  anterior  surface  of  the  spinal  column, 
the  diaphragm,  scaleni,  and  muscles  of  the  tongue  and  larynx 
are  chiefly  chosen,  but  no  muscles  are  safe  from  their 
incursions. 

The  muscle-trichina  penetrates  into  the  interior  of  a 
muscular  fasciculus  and  feeds  upon  the  contractile  substance. 
After  it  has  grown  to  a  length  of  1  mm.  the  so-called  "  encap- 
sulation "  of  the  worm  ensues.  It  rolls  itself  spirally  together 
and  remains  without  change  of  place  or  position  for  years  at 
a  time.  In  the  meantime  the  muscular  fasciculus  is  completely 
destroyed.  Two  capsules  are  formed  :  an  inner  one  belonging 
to  the  animal  proper,  and  an  outer  connective-tissue  capsule, 
richly  provided  with  blood  vessels.  The  former  is  homoge- 
neous, transparent  and  reasonably  dense.  After  it  becomes 
calcified  the  trichinae  are  readily  seen  with  the  naked  eye  in  a 
freshly  prepared  section,  while  at  other  times  a  careful  micro- 
scopical examination  is  required.  The  outer  capsule  supplies 
the  animal  with  an  abundant  blood  interchange,  so  that  its 
life  is  preserved  even  in  the  calcified  investment. 

A  further  stage  of  development  comes  when  the  meat  is 
eaten  in  a  raw  or  half-cooked  condition.  Pork  in  the  latter 
condition  is  especially  dangerous  to  eat,  and  the  flesh  of  rats 
for  swine.  The  gastric  juice  in  the  stomach  eventually  dis- 
solves the  calcified  capsule  and  liberates  the  trichinae,  which 
in  a  few  days  arrive  at  a  sexual  state.  Thus  begins  anew  the 
cystic  development  before  described. 

Very  soon  after  eating  meat  infected  with  trichinae  a 
violent  pain  is  felt  in  the  intestines,  and  painful  intestinal 
catarrhs  set  in,  which  are  like  those  of  cholera.  Then 
comes  the  migration,  accompanied  by  fever,  pain  in  the  mus- 
cles, and  paralyses  which,  if  they  attack  the  laryngeal  and 
respiratory  muscles,  are  liable  to  be  immediately  fatal.  The 
danger  is  greatest  about  the  fifth  week  after  the  fatal  meat 
has  been  partaken  of.  The  lethal  result  is  indicated  by  in- 
creasing weakness  of  respiration,  cyanosis,  anasarca,  and  lastly, 
pulmonary  oedema. 

Filaria  medinensis.  Guinea  worm.  A  thread-like  worm, 
of  the  thickness  of  a  violin  string,  and  reaching  a  meter  in 
length.  Found  exclusively  in  the  tropics,  especially  in 


210  GENERAL    PATHOLOGY. 

Guinea.    Causes  painful  abscess  of  the  skin,  chiefly  on  the  leg 
and  heel.     It  was  known  to  Galen. 

Filaria  sanguinis  hominis.  Smallest  animal  parasite  which 
infests  the  human  body.  Only  0.35  mm.  long,  and  0.006  mm. 
in  diameter.  Lives  in  great  numbers  in  the  blood,  from 
whence  it  settles  in  the  kidneys  and  produces  hsematuria. 
Only  found  in  the  tropics  (Egypt,  India,  Bahia,  Gaudeloupe). 

Trematodes. 

All  flat  worms  have  a  flat,  leaf-like,  unarticulated  body, 
and  are  provided  with  a  single  opening  which  serves  both  as 
mouth  and  anus,  and  which  leads  into  a  short,  bifurcated 
intestinal  canal.  This  opening  is  found  on  the  pointed 
anterior  portion  of  the  body,  at  the  bottom  of  a  sucker  ; 
close  at  hand  is  the  genital  pore,  and  back  of  that  is  a  still 
larger,  abdominal  sucker. 

Distomum  hepaticum.  A  broad,  brown,  flat  body,  2.8  cm. 
long,  1.2  cm.  broad,  with  a  short  wide  disk  (head).  The 
coiled  con  volutions  of  the  female  genital  apparatus  form  a  dark 
blue  spot  behind  the  abdominal  sucker.  The  ovaries  are 
situated  on  the  sides  of  the  body,  between  them  the  seminal 
canals.  The  distomum  hepaticum  has  both  male  and  female 
organs  of  generation. 

It  occurs  in  a  sexually  mature  condition  in  many  of  the 
mammalia,  in  the  biliary  ducts  of  the  liver,  and  causes,  in 
sheep,  what  is  known  as  "liver  rot."  Rarely  found  in  the 
human  body. 

Time  will  not  permit  a  detailed  description  of  the  interesting 
metamorphoses  of  the  distomum  hepaticum,  by  means  of 
which  the  "  generation  changes  "  in  these  animals  have  been 
discovered  (Cercaria,  nursing  conditions,  etc.) 

Distomum  lanceolatum.  Distinguished  from  the  large  liver 
distomum  by  its  small  size  and  its  narrow,  lance-shaped  body. 
In  other  respects  it  is  synonymous,  both  in  place  and 
manner  of  living.  Leuckhart  once  found  forty-seven  speci- 
mens of  the  distomum  lanceolatum  in  the  gall-bladder  of  a 
shepherd  girl. 

Distomum  hcematobium.  Here  we  must  distinguish  between 
male  and  female.  The  male,  1.2-1.4  cm.  long,  has  an  oblate 
body,  hollowed  out  like  a  gutter-pipe,  in  which  cavity  the 
perfectly  cylindrical  body  of  the  female  has  often  been  found 
reposing. 


PARASITIC  AND   INFECTIOUS   DISEASES.  211 

The  distomum  hsematobium  is  a  pest  to  the  Upper  Egyp- 
tians and  Abyssinians.  They  pass  apparently  from  the 
intestines  into  the  blood,  from  whence  they  deposit  their  egga 
in  the  mucous  membranes  of  the  urinary  apparatus  and  the 
intestinal  tract.  The  ulcerations  produced  at  these  points  by 
the  development  of  the  embryos  are  responsible  for  the  fre- 
quency of  kidney  and  calculous  diseases  in  Egypt. 

Cestodes. 

The  cestodes  are  flat,  tape-like,  intestinal  parasites,  of  a 
white  color,  consisting  of  a  short-necked  tapeworm  head 
(Scolex),  and  a  long  chain  of  tapeworm  segments.  The  head, 
smaller  than  a  pin's  head,  is  provided  with  suckers. 

The  neck  is  a  fine  thread,  to  which  the  first  narrow  seg- 
ments are  attached.  Further  on,  the  segments  become  distinct, 
broad,  and  flat,  and  finally  develop  to  ten  times  the  width  of 
the  head  and  to  a  corresponding  length,  after  which  the 
mature  tapeworm  segments  (proglottides)  appear  as  elongated 
plates  in  the  shape  of  a  melon  seed,  and  are  broken  off 
and  discharged  with  the  faeces.  During  this  time  there  has 
been  developed  in  each  segment  of  the  tapeworm,  both  a 
male  and  a  female  genital  apparatus,  the  latter  of  which 
is  crowded  with  eggs  at  the  time  of  discharge.  With  the 
exception  of  two  fine  "water  vessels"  situated  at  the  sides 
of  the  worms,  there  are  no  internal  organs  visible.  Nutri- 
tion is  supplied  by  osmosis  directly  from  without,  which 
is  made  possible  by  the  flattened  shape  of  the  segments. 
The  whole  color  of  the  tapeworm  is  due  to  spherical  particles 
of  limestone,  distributed  throughout  the  entire  bodily  pa- 
renchyma. It  is  maintained  that  the  tapeworm  is  able 
to  execute  movements  on  a  large  scale,  to  curl  itself  up, 
for  instance  ;  I  have  personally  observed  that  the  freshly- 
discharged  proglottides  exhibit,  while  still  warm,  a  peculiar 
quick  motion. 

In  most  tapeworms  there  is  a  complex  metamorphosis  con- 
nected with  generation,  inasmuch  as  the  embryos  upon 
emerging  from  the  eggs,  instead  of  remaining  in  the  intestinal 
canal  of  the  new  host,  perforate  the  intestinal  wall  and  enter 
the  connective  tissue  and  the  blood.  Having  located  them- 
selves in  a  favorable  spot,  they  develop,  first  of  all,  into  the 
cysticercus  or  the  "  bladder  worm  "  of  the  Finlander.  This 
cysticercus  may  remain  for  some  years  or  may  finally  perish ; 


212  GENERAL   PATHOLOGY. 

if,  however,  it  in  any  way,  while  living,  reaches  the  alimentary 
canal  of  the  particular  class  of  animal  which  it  infests  in  its 
mature  condition,  it  becomes  attached  by  the  head,  the 
vesicle  falls  off,  and  then  a  succession  of  segments  form, 
constituting  the  tapeworm. 

Tcenia  solium  and  Cysticercus  cellulosce.  Taenia  solium  in- 
habits the  small  intestines  of  man.  The  cubiform  head,  of 
the  size  of  a  pin's  head,  is  furnished  with  four  prominent 
suckers.  In  front  of  them  is  the  rostellum,  a  slightly  promi- 
nent conical  snout,  surrounded  by  a  double  row  of  curved 
hooks.  These  hooks  appear  capable  of  being  elevated  out 
of  and  inserted  into  corresponding  grooves  in  the  sur- 
rounding parenchyma.  That  portion  of  the  head  opposite  the 
rostellum  is  occupied  by  the  neck  of  the  scolex.  The  scolex 
matures  oblong  links  or  segments,  each  of  which  encloses  a 
part  of  the  preceding  one.  The  ovaries  form  clustering 
appendages  of  a  central  canal,  which  terminates  in  a  small 
projection  at  the  side  of  the  body.  The  aperture  of  the  much 
smaller  masculine  genital  apparatus  is  also  found  at  this 
point.  It  is  marked  by  a  baggy  sac,  the  cirrus,  which  is 
regarded  as  the  copulative  organ. 

The  eggs,  which  are  almost  round,  have  thick,  radiatingly- 
striated  shells.  Nature  has  ordained  that  they  should  be 
received  into  the  stomach  and  intestines  of  swine  by  the 
ingestion  of  human  faeces.  Here  the  shell  is  dissolved  and  the 
embryo  released.  Migration  begins  at  once  and  the  parasite 
penetrates  into  the  porous  connective  tissue,  and  reaches,  often 
in  a  roundabout  way,  the  very  spots  which  best  favor  its 
development  into  a  cysticercus.  Such  localities  are  the  con- 
nective tissue  of  the  muscles,  the  pia  mater  cerebri,  the 
vitreous  body  of  the  eye.  The  embryo — thus  far  a  simple 
mass  of  protoplasm  furnished  with  six  hooks — is  now  con- 
verted into  a  vesicle  filled  with  a  clear  liquid,  and  attains  in 
two  or  three  months'  time  the  size  of  a  pea.  In  this  shape 
the  worm  is  found,  by  the  hundred  and  thousand,  in  "  measly" 
pork. 

Such  a  vesicle  is  easily  moved  from  its  position.  A  white 
spot  is  then  visible,  from  which,  upon  gentle  pressure,  a  genu- 
ine tapeworm  head  may  be  squeezed  out.  This  has  been  con- 
cealed in  a  corresponding,  pouch-like  contraction  of  the 
vesicle  wall,  upon  the  surface  of  which  it  has  been  formed,  in 
a  manner  as  yet  unexplained. 


PARASITIC   AND   INFECTIOUS   DISEASES.  213 

It  has  been  proved  by  numerous  experiments  that  the 
taenia  soliurn  is  taken  into  the  small  intestines  of  man  by  the 
consumption  of  "  measly"  pork.  The  injuries  inflicted  by 
these  tseuias  are  often  overrated,  but  it  appears  that  they  may 
give  rise  to  irregularities  of  digestion,  inclination  to  diarrhoea, 
etc.,  and  in  delicate  and  sensitive  organisms  moreover,  to 
nervous  symptoms  amounting  to  slight  convulsions. 

Of  more  serious  moment  is  the  appearance  of  the  cysticercus 
cellulosse  in  man.  It  is  difficult  to  say  how  the  tapeworm 
eggs  are  transmitted  from  the  feeces  to  the  mouth.  It  may  be 
by  inhalation  of  the  dried  particles.  It  is  not  a  frequent 
visitor,  but  when  it  does  appear  its  deposition  in  the  eye 
threatens  that  member  with  dimness  of  the  lens,  with  iritis 
and  choroiditis,  or  with  total  loss  of  the  organ ;  its  deposition 
in  the  pia  mater  of  the  brain  and  in  the  ventricles  brings  on 
cerebral  disturbances  and  lepto-meningitis.  If  the  cysticerci 
are  seated  superficially  in  the  muscles,  they  may  occasionally 
be  felt  under  the  skin,  thus  furnishing  criteria  for  diagnosis. 

Tcenia  medio-cannellata.  It  bears  a  general  resemblance  to 
tsenia  solium,  with  the  following  differences  :  Its  length  and 
breadth  are  usually  greater ;  head  larger,  2.5  mm.  in  diameter  ; 
it  has  neither  rostellum  nor  hooks,  but  its  four  suckers  are 
very  prominent  and  powerful.  The  ripe  proglottides  are  long 
and"  very  full  of  eggs.  Proglottides,  in  order  to  develop,  must 
find  their  way  into  the  intestines  of  cattle,  from  which  point 
the  embryos  wander  out  into  the  muscles  and  internal  organs. 
Beef  thus  affected  infests  man,  when  consumed  by  him  as  food. 

Tsenia  medio-cannellata  is  indigenous  to  every  part  of  the 
globe,  while  tsenia  solium  is  rare  in  southern  countries.  The 
pathological  conditions  produced  by  both  are  identical. 

Tcenia  echinococcus.  This  smallest  of  all  known  tsenias 
lives  in  the  intestinal  canal  of  the  dog.  It  is  a  tapeworm 
consisting  of  only  four  links  and  scarcely  a  half  centimeter  in 
length.  Half  of  this  length  is  occupied  by  the  fourth  sexually 
mature  link.  The  head  is  a  perfect  tapeworm  scolex,  with 
suckers  and  a  rostellum  surrounded  by  hooks.  Experience 
has  proved  that  the  intimate  association  of  dogs  with  men 
may  lead  to  an  infection  of  the  latter  by  the  tapeworm  eggs. 
The  embryos,  becoming  released  in  the  intestine  of  man  (as 
well  as  in  those  of  other  warm-blooded  animals),  pass  imme- 
diately through  the  intestinal  wall  into  the  blood  vessels  and 


214  GENERAL    PATHOLOGY. 

connective  tissue.  Through  the  vena  porta  they  gain  access 
to  their  favorite  abode,  the  liver.  They  may  also  be  found  in 
the  loose  sub-serous  connective  tissue  of  the  peritoneum  ;  in 
the  sub-mucous  connective  tissue  of  the  urinary  ducts ;  in  the 
lungs ;  and,  in  fact,  occasionally,  in  almost  any  of  the  bodily 
organs. 

There  now  ensues  the  development  of  the  embryo  into  the 
well-known  echinococcus  cyst,  whose  enormous  size  is  quite  dis- 
proportionate to  that  of  the  original  tsenia.  The  steady 
accumulation  of  a  clear  fluid  internally  keeps  pace  with  the 
growth  of  its  cuticle,  which  becomes  a  millimeter  in  thickness, 
and  is  of  the  consistency  and  milk-white  color  of  coagulated 
albumen.  It  is  finely  laminated,  and  contains  here  and  there 
spaces  filled  with  granular  parenchyma,  while  its  entire  inner 
surface  is  furnished  with  a  thin  parenchymatous  layer. 
From  the  parenchyma  islets  in  the  interior  of  the  cuticle,  a 
new  vesicular  formation  can  take  place  simply  by  a  con- 
tinuous accumulation  of  fluid  and  the  formation  of  a  cuticular 
layer.  The  secondary  or  daughter-cysts  force  themselves 
into  the  interior  of  the  mother-cyst.  Dozens  of  these 
daughter  cysts  are  often  found  inside  of  the  mother  cyst. 
They  range  in  size  from  a  pea  to  a  hen's  egg,  and  the  mother 
cyst  in  which  they  are  enclosed  attains  occasionally  the 
size  of  a  child's  head.  New  scolices,  as  a  rule,  are  only 
developed  inside  of  the  daughter  cyst.  They  arise  by  threes 
or  fours  on  the  inner  surface  of  certain  stalked  protoplasmic 
capsules,  large  numbers  of  which  hang  down  from  the  wall. 
Were  it  not  for  the  thickness  of  the  cyst  wall,  which  limits 
the  whole  process  of  growth  to  the  interior,  these  protoplasmic 
projections  would  probably  form  just  such  open  pouches 
outwards,  as  occurs  with  cysticercus  cellulosse.  As  it  is,  the 
echinococci  scolices  have  little  prospect  of  development. 
Unless  something  unforeseen  occurs,  the  whole  cyst  dies  in  loco, 
and,  in  a  favorable  case,  is  also  buried  in  loco,  i.  e.,  infiltrated 
with  salts  of  lime. 

In  less  favorable  cases  the  cysts,  upon  reaching  the  size  of 
a  hen's  egg,  produce  all  sorts  of  inflammatory  reactions  in 
their  neighborhood.  A  connective  tissue  capsule  always  forms 
around  the  cyst.  But  this  is  not  all.  A  trauma  of  the  hepatic 
region  occasions  a  suppurative  "  abscess-forming  "  inflamma- 
tion, which  may  discharge  itself  externally.  It  can  only  be 
thrown  off  from  the  lungs  by  means  of  a  similar  inflaru- 


PARASITIC   AND   INFECTIOUS   DISEASES.  215 


matiou  ; 


ion  ;    more  easily,  as   it  seems,  by  way  of  the  urinary 
sages.    The  echinococcus-cysts  have,  furthermore,  the  effect 


of  tumors  upon  the  neighboring  organs,  and  of  thrombi  and 
emboli  upon  the  lumen  of  the  blood  vessels  which  they  inhabit. 

There  is  a  species  of  echinococcus  in  cattle,  where  the 
daughter  cyst  grows  outward  instead  of  inward.  It  is  pos- 
sible that  it  is  the  same  species  which  in  man  is  designated  as 
echinococcus  multilocularis.  Here  we  find  in  the  liver  a  spot 
as  large  as  a  goose-egg  converted  into  a  tough,  callous  mass  of 
connective  tissue,  permeated  with  numbers  of  echinococcus 
cysts  as  small  as  a  pin's  head.  Within  this  focus  is  found, 
as  a  product  of  impaired  nutrition,  a  "  centre  of  softening," 
which  the  physician  pronounces  an  abscess  of  the  liver,  from 
which  it  differs  little  in  clinical  importance. 

Bothriocephalus  latus.  The  full  grown  tapeworm  measures 
5-8  mm.  The  thread-like  neck  bears  the  head,  which  is 
a  club-shaped  or  obtuse  swelling  2.5  mm.  long,  1  mm.  wide, 
with  two  long  grooved  suckers  (podptov).  The  segments  of 
the  worm  measure  more  laterally  than  longitudinally,  but 
the  last  proglottides  are  somewhat  quadrangular.  The  sexual 
pore  is  situated  in  the  middle  on  the  surface,  and  is  surrounded 
by  the  puckered-up,  brownish-colored  uterus,  with  which  it 
forms  a  raised  hump.  It  is  found  in  the  western  cantons 
of  Switzerland  and  in  the  northeast  of  Europe. 

Infusoria. 

"We  may  reckon  with  the  parasitic  infusoria  which  are 
found  in  the  intestinal  and  vaginal  mucous  membrane — cerco- 
manas  intestinalis,trichomanas  vaginalis — some  protozoa  which 
are  occasionally  met  with  in  the  liver  and  muscles.  They  do 
not  occasion  any  particular  injury  by  their  presence.  The 
one-celled  infusoria  are  termed  "  psorospermia,"  and  colonies  of 
them  in  closed  membranous  investments  0.5-1  mm.  in  length, 
are  called  psorospermia  cylinders. 

(&)    VEGETABLE   PARASITES. 

Mould  Fungi. 

Aspergillus  glaucus.  The  greenish  mould  which  grows  on 
walls  is  composed  of  an  elongated,  cross-partitioned,  loose 
mycelium,  which  sends  out  thick,  perpendicular,  thread-like 
offshoots.  When  the  latter  attain  a  length  of  .5  mm.,  their 
extremities  become  club-shaped.  From  the  letter  radiated 


216  GENERAL  PATHOLOGY. 

projections,  the  so-called  sterygmata  arise,  from  which  chains 
of  ten  or  more  spherical  spores  are  given  off. 

If  these  spores  are  injected  into  the  blood  of  a  squirrel, 
they  lodge  in  the  most  dissimilar  organs,  among  others,  in  the 
brain  and  kidneys,  where,  encouraged,  as  it  seems,  by  the  high 
temperature,  they  develop  rapidly  into  a  fibrous  mycelium. 
Local  inflammations  set  in,  which,  if  excessive,  become  dan- 
gerous, and  even  fatal. 

A  non-artificial  mycosis  aspergillina  has  not  yet  been  ob- 
served. The  spores  of  aspergillus  niger,  penicillium  glaucum, 
mucor  mucedo,  the  most  common  of  the  mould  fungi,  do  not 
germinate  in  the  bodily  parenchyma.  They  have,  however, 
occasionally  been  found  in  the  external  auditory  canal. 

Achorion  Schonleinii.  The  spores  are  deposited  in  the  oily 
moisture,  which  surrounds  the  cast-off  epithelium,  enveloping 
the  roots  of  the  hairs.  They  grow  here  into  thin,  jointed 
threads,  which  are  only  slightly  ramified,  and  which  send  out 
from  short,  alternating  lateral  shoots  short  chains  of  obovate 
spores.  When  water  is  added,  the  latter  spring  away  from 
each  other,  and  develop  at  the  same  time  into  round,  yellow- 
ish globules,  which  agaiu  proceed  to  germinate.  When  de- 
prived of  nourishment,  the  cells  of  the  mycelium  threads  form 
dark  green,  permanent  spores,  each  containing  two  nuclei. 

The  deposition  of  the  achorion  schonleinii  produces  "  scald 
head  (tinea  favosa).  The  whole  head  is  often  covered  with 
yellow,"  pea-sized  scabs,  in  flakes  and  discs.  The  skin  is 
attenuated  under  each  scab,  but  soon  recovers  upon  the 
extermination  of  the  fungus,  which  is  easily  accomplished. 

Trichophyton  tonsurans.  A  parasite  of  the  true  hair  shaft, 
whose  spores  are  fixed  at  the  point  where  the  hair  emerges 
from  the  skin,  and  which  proliferate  from  here  directly  into 
the  interior  of  the  hair.  Having  formed  long  chains  of 
fungus  cells,  they  force  the  hair  cells  apart  and  at  length  pro- 
duce a  loss  of  continuity.  The  hair  falls  out  as  soon  as  the 
diseased  spot  in  the  shaft  has  grown  about  2mm.  above  the 
surface  of  the  skin.  Bald  spots,  i.  e.,  where  there  are  only  a 
few  broken  off  hairs,  mark  the  deposition  of  this  fungus 
(herpes  tonsurans).  It  is  easily  eradicated  by  destroying  the 
fungus. 

Microsporon  furfur  forms  in  the  lower  epidermal  layers  a 
mycelium  composed  of  unarticulated  threads,  which  mature 
within  them  numbers  of  round  spores.  Certain  pale  brown, 


PARASITIC   AND   INFECTIOUS   DISEASES.  217 

roundish  spots  .5-5  cm.  in  diameter,  are  thus  formod  (pityriasis 
versicolor). 

The  breast,  back  and  upper  portions  of  the  arms  are  the 
favorite  seats  of  the  microsporou  furfur. 

Oidium  albicans  forms  a  mycelium  consisting  of  rather 
thick  and  succulent  filaments,  which  are  constricted,  four-sided, 
and  rounded  off  at  the  point  of  contact.  These  filaments  con- 
tain the  glistening  spores. 

This  fungus  is  found  in  certain  yellowish-white,  circum- 
scribed and  easily  detached  depositions  in  the  mouth  and 
pharynx,  as  well  as  in  the  oesophagus  of  nursing  children,  or 
even  of  adults  exhausted  by  a  long  illness.  The  depositions 
contain,  besides  the  fungi,  portions  of  cast-off  pavement 
epithelium  and  of  food,  chiefly  wheat  bread  (known  in  medi- 
cal terminology  as  Thrush  or  Aphthae.) 

Yeast  Fungi. 

Sarcina  ventriculi.  In  chronic  stomach  troubles,  where  the 
contents  of  the  stomach  display  abnormal  processes  of  fermen- 
tation and  decomposition,  we  find  at  times  a  lower  order  of 
parasites,  which  consist  of  minute  cubical  cells.  The  fact  that 
these  are  always  in  groups  of  four,  and  resemble  a  cubiform, 
cross-like  constricted  peddler's  pack,  has  given  rise  to  the 
name  of  sarcina.  Appears  to  belong  to  the  yeast  fungi. 

Cleft  Fungi. 

The  Schizophytes  are  the  smallest  plants,  indeed  the  very 
smallest  living  creatures.  Some  of  the  pathogenetic  schizo- 
phytes are  inconceivably  minute,  but  there  are  a  number 
which  may  be  recognized  with  an  ordinary  microscope,  and 
made  distinct  by  using  the  proper  staining  fluids  and  good 
illumination,  so  that  even  now,  where  we  are  as  yet  upon  the 
threshhold  of  the  science  of  microphytic  diseases,  we  can 
command  much  definite  information  in  regard  to  the  natural 
history  of  the  pathogenetic  schizophytes. 

All  cleft  fungi  are  in  structure  globular,  rod-shaped,  or 
spiral,  being  composed  of  a  colorless  homogeneous  substance, 
whose  refractive  powers  vary  widely  in  the  different  species. 
Many  of  them,  when  suspended  in  water,  show  a  lively  indi- 
vidual mobility,  and  when  the  remaining  conditions  are  fur- 
nished, i.  e.,  suitable  food  and  temperature,  apply  themselves 
without  delay  to  the  main  end  of  their  being,  to  propagation 
'5 


218  GENERAL    PATHOLOGY. 

by  simple  cleavage  (<j-/^?).  This  supposes  a  moderate 
growth  by  internal  apposition  to  have  already  taken  place. 
As  soon  as  the  granules  attain  a  certain  circumference,  and 
the  rods  a  certain  length,  they  separate  in  the  middle. 

Every  fungus  is  enveloped  in  a  juice-layer  or  sheath  of  its 
own,  whose  consistency  is  regulated  by  the  amount  of  surround- 
ing water,  which,  accordingly,  either  checks  or  encourages  any 
possible  activity  of  the  fungi  as  well  as  the  displacements 
necessary  to  their  growth.  If  the  schizophytes  settle  upon 
surfaces,  which,  although  moist,  are  not  liquid,  the  mucous  or 
gelatinous  consistency  of  the  sheath  above  mentioned  prevents 
the  cleft-fungi  from  separating  from  each  other,  although 
they  continue  to  proliferate  within  themselves;  the  sheath 
represents  a  common  covering  for  the  entire  progeny  of  a 
parasite,  and  as  proliferation  by  division  continues,  there 
arise  of  necessity  large  colonies,  which  have  been  called  by 
F.  Cohn,  zooglcea  aggregations.  The  latter  are  round,  or 
roundish  in  shape,  and  become  so  large  that  they  are  even 
visible  to  the  naked  eye.  They  are  most  perfectly  developed 
in  the  semi-solid  nutritive  gelatines,  which  are  now,  according 
to  Koch's  formulae,  most  frequently  employed  in  cultivating 
the  individual  species  of  schizophytes.  So  varied  are  they  in 
form  and  color,  according  to  the  kind  of  schizomycetes  sown, 
and  yet  so  characteristic  of  each  particular  kind,  that  it  is  far 
easier  to  determine  the  species  from  these  colonies  than  from 
the  shape  of  the  individual  bodies. 

The  color  of  the  schizophyte  colonies  is  exclusively  in  the 
investment  juices  of  the  fungi.  The  latter  is  often  of  a 
dazzling  yellow,  blue  or  red  color,  but  the  fungus  itself  is 
seen  upon  close  examination  to  be  quite  colorless,  a  proof, 
moreover,  that  important  physiological  differences  may  co-exist 
with  the  somewhat  overrated  homogeneity  of  schizophytes. 

Whenever  the  conditions  necessary  to  the  growth  of  the 
schizophytes  are  not  fully  satisfied,  there  arises  a  modified  de- 
velopment, which,  in  the  higher  plant  world,  is  known  as  the 
formation  of  spores  and  ova.  The  rods,  instead  of  growing 
longer,  gather  protoplasm  at  one  or  more  points,  which  points 
resemble  roundish,  shining  balls  ;  each  of  these  balls,  envel- 
oped by  a  thick,  self-prepared  capsule,  represents  a  germ, 
which  only  awaits  the  return  of  suitable  conditions  of  growth 
— water,  food,  temperature,  etc. — to  again  expand  into  a  rod 
and  resume  the  process  of  division. 


PARASITIC   AND   INFECTIOUS   DISEASES.  219 

Many  of  these  germs,  especially  those  bearing  flagella,  con- 
tribute, by  their  own  mobility  in  water,  somewhat  towards  the 
selection  of  a  new  abode.  Most  of  them  become  so  extremely 
light  alter  dessication  that  the  slightest  breath  of  air,  even 
the  courant  ascendant  of  every  warm  human  body,  suffices  to 
lift  and  carry  them  away.  Thus  it  is  that  the  schizophytes 
represent  one  of  the  constant  elements  of  dust,  and  that  un- 
usual precautions  must  be  taken  to  entirely  rid  a  place  from 
them.  It  is  only  after  prolonged  rains  that  the  atmosphere  is 
quite  free  from  schizophytes  and  then  only  for  a  short  time. 

Pasteur  urges  a  division  of  the  entire  tribe  of  schizophytes 
into  those  requiring  air  and  those  not  requiring  air.  The 
latter  separate  the  oxygen  which  they  require  for  their  growth 
from  the  combined  gases  of  the  soil  upon  which  they  feed. 
They  are,  accordingly,  well  adapted  to  assist  in  the  decompo- 
sition of  organic  bodies,  and  represent  the  great  group  of  de- 
composition fungi  in  the  broadest  sense  of  the  word.  The 
others,  which  cannot  live  unless  surrounded  by  pure  oxygen, 
are,  in  consequence,  more  restricted  as  to  their  abode.  As  a 
general  thing,  they  can  only,  like  the  mould  fungi,  exist  upon 
the  damp  surfaces  of  some  fostering  soil,  and  are,  on  the  whole, 
of  less  importance.  Unfortunately,  however,  the  presence  of 
"  free  oxygen  in  the  blood"  affords  them  an  entrance  into  the 
body,  and  the  schizophytes  requiring  air  become  thus  one  of 
our  most  dangerous  foes. 

Many  pathogenetic  schizophytes  reside  at  present  exclusively 
in  the  human  body.  Still  we  cannot  assume  that  this  has 
always  been  the  case,  but  must  rather  concede  the  possi- 
bility of  Darwin's  theory,  according  to  which  the  gradual 
accommodation  of  the  schizophytes  to  the  human  body  has,  by 
a  local  specializing  process,  effected  an  alteration  in  their 
vital  qualities.  The  possibility  that  such  a  process  of  accli- 
mation and  transformation  might  still  take  place  is  suggested 
by  the  occasional  outbreak  of  entirely  new  infectious  diseases. 
It  is  not  only  improbable,  but  also  unnecessary,  to  assume 
that  every  new  chain  of  individual  sicknesses,  every  so-called 
epidemic,  requires  a  new  acclimation  and  transformation. 
The  very  development  of  the  countless,  permanent  spores  in 
only  one  case  of  disease  furnishes  countless  germs,  the  very 
fewest  of  which  only  need  to  find  a  sheltered  dwelling-place, 
in  order  to  create,  at  the  proper  time,  a  new  epidemic. 

The  manner  of  acclimation  is  a  much-disputed  point  in  the 


220  GENERAL    PATHOLOGY. 

study  of  fungi.  According  to  Buchner,  Nageli's  pupil, 
artificial  culture  has  proved  that  a  certain  hay  fungus,  re- 
sembling outwardly  the  schizophyte  of  anthrax,  will  not, 
when  taken  freshly  from  the  hay,  vegetate  in  blood  which  has 
been  inoculated  with  it.  But  cultivate  the  fungus  first  in 
cold,  then  in  warm,  albuminous  solutions,  and  it  soon  attains  a 
capacity  fully  equal  to  that  of  the  common  fungus  occurring 
in  anthrax.  These  results,  if  universally  recognized,  would 
furnish  a  fair  representation  of  the  manner  of  breeding.  In 
the  meantime,  they  are  supported  by  investigations  into  the 
general  and  historical  course  of  some  infectious  diseases, 
which  almost  indicate  that  the  fungus  under  consideration 
must  have  first  settled  in  certain  mucous  or  purulent  products 
upon  some  point  of  the  bodily  parenchyma  before  it  sought 
and  found  a  way  into  the  interior.  The  apparently  sudden 
outbreak  of  devastating  plagues,  like  cholera,  syphilis  or 
diphtheria,  is  best  explained  by  supposing  that  a  fungus  grow- 
ing as  an  epiphyte  has  suddenly  gained  the  power  of  growing 
as  an  endophyte,  thus  creating  an  apparently  new  infection. 

The  acclimation  of  the  fungus  in  the  body  is  fortunately 
counterbalanced  by  the  acclimation  of  the  body  to  the  fungus. 
The  vegetation  of  the  body  learns  to  resist  the  invading 
fungus  growth.  This  power  has  been  gained  in  hard  but 
successful  struggles  against  great  numbers  of  dangerous 
adversaries,  as  well  as  in  the  slighter  exertions  required  to 
overcome  the  incorporation  of  less  formidable  foes,  which  are 
by  nature  weaker,  or  have  become  so  by  artificial  means. 
How  this  is  accomplished,  and  in  what  tissue  change  the  im- 
munity resides,  by  which  the  naturally  or  artificially  inocu- 
lated body  defies  the  plague,  is  unknown.  We  cannot  yet 
unravel  the  mystery.  We  only  know  that  the  course  of  many 
infectious  diseases  is  thereby  mitigated  or  entirely  checked. 
And  what  is  true  of  the  individual  is  also  true  of  the  entire 
race  and  its  relations  to  plagues  and  national  diseases.  Na- 
tional diseases  have  also  an  ascendant  and  descendant  stage  of 
intensity,  in  proportion  as  the  race  learns  to  accommodate 
itself  to  the  vegetation  of  the  respective  schizomycetes.  Partly 
because  the  poison  is  taken  up  in  small  quantities,  which  by 
degrees  are  spread  more  and  more  over  the  surface  of  the 
earth,  and  becomes  thereby  more  and  more  diluted ;  and 
partly  by  inheritance,  viz.,  syphilis,  tuberculosis,  leprosy,  the 
poison  is  finally  communicated  to  constantly  increasing  num- 


PARASITIC   AND   INFECTIOUS    DISEASES.  221 

bers  of  people,  and  produces  in  them  a  relative  immunity 
against  renewed  infection. 

But  we  must  conclude  here,  in  order  not  to  rob  the  consid- 
eration of  the  individual  schizophytes  of  its  legitimate  mate- 
rial. The  above  suffices  to  show  how  easily  the  so-called 
fungus  theory  may  be  introduced  into  the  domain  of  infectious 
diseases,  and  also  to  justify  myself  if  I  unreservedly  support 
the  same. 

As  we  are  at  liberty  to  select  any  particular  vital  quality  of 
the  pathogenetic  schizophyte  as  a  basis  for  the  division  of  "the 
same,  we  shall  not  hesitate  to  proceed  from  the  already  well 
established  standpoint  concerning  the  theory  of  miasm  and 
contagion.  Hence  according  to  the  substratum  (soil  ?)  in 
which  the  pathogenetic  microphyte  gains  those  qualities 
which  prepare  it  to  invade  and  infect  man,*  we  divide  them 
into : — 

1.  Microphytes  which  live  and  feed  outside  the  body,  par- 
ticularly in  soil  which  is  damp,  exposed  to  the  air,  and  filled 
with  decayed  organic  matter,  and  from  which  they  can  be 
readily  inhaled  and  reach  the  blood  of  man.     Here  they  pro- 
liferate, and  produce  a  feverish  condition  in  the  entire  body, 
but  do  not  appear  in  the  excretions  of  the  patient,  as  germ- 
producing  spores.      The   microphytes  are,  consequently,   re- 
stricted  to  certain   localities,  which,  although  sometimes   of 
considerable  extent,  are   only  dangerous,  i.  e.,  productive  of 
endemics   to    those  who    live  in   them   or  frequent    them. 
Miasmatic  microphytes. 

The  chief  representative  of  the  diseases  due  to  miasmatic 
microphytes  is  malaria,  in  all  its  forms,  viz.,  the  simple  inter- 
mittent, the  anomalous  and  irregular  intermittent,  the  perni- 
cious, remittent  and  protracted  swamp  fever,  and  the  malarial 
cachexia.  The  malarial  fungus  has  not  yet  been  identified. 
Klebs  and  Tommasi  have  directed  attention  to  a  bacillus  pro- 
cured in  the  notorious  malarial  districts  near  Rome. 

2.  Microphytes,  which,  like  the  miasmatic  microphytes,  re- 
quire a  soil  outside  of  the  body,  in  order  to  produce  those 

*  Only  those  microphytes  will  be  considered  which  have  been  defi- 
nitely pronounced  to  be  the  exclusive  cause  of  a  well  known  infectious 
disease.  To  establish  this  rule,  from  which  I  shall  make  but  few 
exceptions,  careful  culture  experiments  must  be  made,  and  the  typical 
recurrence  of  all  symptoms  of  disease  must  result,  when  the  material 
thus  obtained  is  carefully  inoculated. 


222  GENERAL    PATHOLOGY. 

forms  of  vegetation  which  are  able  to  infect  roan  and  produce 
a  characteristic  disease.  They  possess,  however,  germinating 
spores,  which  pass  into  the  faeces  and  emanations  of  the 
patient,  and  are  themselves  capable  of  impregnating  another 
soil  outside  of  the  body,  where  they  then  ripen  into  infectious 
shapes.  The  vegetation  of  these  microphytes  is,  as  we  see, 
more  and  more  transferred  to  the  human  body,  with  a  pro- 
portionate emancipation  from  the  external  soil.  The  micro- 
phyte thus  becomes  transportable,  and  the  disease  assumes  less 
of  an  endemic  and  more  of  an  epidemic  character,  although 
its  epidemic  diffusion  is  still  confined  to  certain  localities, 
such  as  dwellings  and  places  of  business.  Such  are  miasma- 
tic-contagious microphytes.  Among  the  diseases  produced 
by  this  order  of  microphyte,  dysentery  approaches  most  nearly 
to  the  purely  miasmatic  forms.  After  that  yellow  fever, 
cholera  and  typhoid  fever.  A  few  points  have  been  gained 
regarding  the  vegetable  originator  of  the  latter  disease,  from 
Eberth,  who  observed  a  medium-sized  bacillus  in  a  specific 
medullary  infiltration  of  typhoid  mesenteric  glands.  The 
cause  of  the  slow  advance  in  this  department  of  science  is 
found  in  the  danger  to  life  accompanying  all  such  experi- 
ments. 

3.  Microphytes  which  have  partially  or  entirely  freed 
themselves  from  an  external  soil,  in  order  to  take  up  their 
habitation  the  more  exclusively  in  the  animal,  i.  e.,  human 
body.  Here  they  multiply,  and  in  the  course  of  a  charac- 
teristic infectious  illness,  produce  offspring,  which  being  trans- 
planted into  a  healthy  and  receptive  body,  are  at  once  pro- 
lific and  pathogenetic.  Contagious  microphytes. 

The  diseases  due  to  contagious  microphytes  may  be  sepa- 
rated into  four  subdivisions. 

(a)  The  first  contains  contagions  whose  free  development 
requires  the  furthering  influences  of  certain  telluric,  atmo- 
spheric, and  other  less  well-known  changes.  To  this  class 
belong  some  of  the  historical  epidemics,  an  example  of 
which  is  the  English  "  sweating  fever."  Also  dengue  fever, 
influenza,  hay  fever,  cerebro-spinal .  meningitis,  spotted  and 
relapsing  fever.  In  relapsing  fever,  we  meet  with  a  more 
generally  known  pathogenetic  microphyte. 

Spirillum  Obermeieri.  Exceedingly  thin,  spiral  filaments, 
0.15-0.2  mm.  in  length,  with  a  rapid  rotary  and  progressive 
motion,  found  in  each  drop  of  blood  withdrawn  and  examined 


PARASITIC   AND   INFECTIOUS   DISEASES.  223 

during  an  attack  of  fever.  Under  a  magnifying  power  of 
400,  the  microscope  shows  in  almost  each  slide  one  or  more 
specimens.  The  parasite  disappears  from  the  blood  at  the 
crisis  of  the  fever,  which  is  usually  accompanied  by  excessive 
sweating. 

All  attempts  at  artificial  culture  have  as  yet  been  fruitless. 
Vaccination  with  blood  drawn  during  relapsing  fever  has 
been  of  marked  success,  as  has  been  proved  especially  by 
Miinch,  by  auto-inoculations.  The  transportation  of  the 
microphyte  in  ordinary  infection  has  thus  far  not  so  much  as 
been  conjectured. 

(6)  The  second  group  of  contagious  diseases  introduces  us 
to  poisons  whose  breeding  places  are  in  the  bodies  of  animals 
rather  than  men,  and  which  are,  in  consequence,  designated 
as  zoonoses.  They  can  only  be  introduced  into  the  human 
body  by  inoculation  (bites,  stings,  etc.),  and  produce  a  dis- 
eased condition,  which,  although  differing  from  the  corres- 
ponding animal  disease,  is  sufficiently  typical  to  establish  the 
identity  of  the  poison.  This  group,  whose  main  representatives 
are  anthrax,  glanders,  hydrophobia  and  mouth  and  foot  pesti- 
lences, contain  the  most  familiar  pathogenetic  microphytes. 

Bacillus  Anthracis.  Anthrax  fungus.  A  good-sized,  some- 
what firm  and  perfectly  immovable  little  rod,  found  in  great 
numbers  in  the  blood  of  cattle,  sheep,  stags,  etc.,  suffering 
from  anthrax.  These  little  rods  are  bred  in  a  temperature  of 
at  least  19°  C.  (66.2  F.),  increase  rapidly  by  division,  and  grow 
into  long  filaments,  which  repeatedly  subdivide,  producing 
finally,  as  a  "  permanent  spore,"  a  very  glossy  globular  struc- 
ture, one  or  two  of  which  are  found  in  each  rod. 

When  inoculated  into  a  small  surface  wound,  the  anthrax 
poison  produces  violent  circumscribed  dermatitis,  accom- 
panied by  necrosis  and  a  blackish  scab,  which  stands  out 
sharply  from  the  reddened  and  oadematous  skin  (malignant 
pustule,  charbon).  When  introduced  with  food,  this  poison 
enters  the  blood  and  gives  rise  to  intestinal  ulceration,  fever, 
severe  cerebral  symptoms  and  hemorrhage,  which  generally 
produce  death. 

The  poisonous  nature  of  the  anthrax  bacillus  may  be  dimin- 
ished by  subjecting  it  to  a  temperature  of  53°  C.  (125.6°  F.), 
and  in  various  other  ways.  It  may  then  be  utilized  for  pre- 
ventive inoculation.  This  inoculation,  however,  only  protects 


224  GENERAL    PATHOLOGY. 

gregarious  animals  against  inoculated  anthrax,  not  from  the 
anthrax  which  attacks  the  body  through  the  intestinal  canal. 
Still,  we  may  look  forward  to  more  successful  preventive 
inoculations  with  a  poison  whose  virulence  is  thus  reduced. 
The  above  measure  was  first  suggested  by  Buchner  and  prac- 
tically applied  by  Pasteur. 

Actinomyces.  Radiated  fungus.  A  micrococcus,  which, 
in  a  favoring  soil  forms  balls  as  large  or  larger  than  a  poppy- 
seed,  from  which  grow  many  fine,  unarticulated,  dichotomous 
ramifying  filaments.  Glossy,  spherical  swellings  of  con- 
siderable size  then  appear  at  the  ends  of  these  filaments,  dis- 
playing longitudinal  cleavage,  and  a  constriction  of  the 
smaller  pieces  at  their  sharp  ends.  The  entire  "  granule  "  is 
bright  yellow  to  brown  in  color. 

Portions  of  these  fungi  are  taken  in  through  the  mouth, 
and  enter  the  body  chiefly  through  carious  tooth  cavities. 
Fistulas  of  the  gums,  and  submaxillary  abscesses  are  formed, 
in  the  pus  of  which  the  yellow  granules  of  the  actinomyces 
are  seen.  The  fungus,  which  now  follows  the  blood  vessels 
and  lymphatics,  produces  abscesses  wherever  it  settles.  The 
lungs,  retro- peritoneum,  mediastinum  and  the  subcutaneous 
connective  tissue  are  favorite  seats  of  such  abscesses,  which 
are  similar  to  those  occurring  in  chronic  pyaemia. 

Actinomyces  occurs  frequently  in  cattle,  rarely  in  man. 

(c)  The  third  group  treats  of  contagions  which,  although 
chiefly  affecting  man,  are  upon  occasion  transmitted  to  certain 
classes  of  animals,  that  is  to  say,  may  be  transmitted  to  them 
by  inoculation.  The  disease  in  animals  shows  certain  typical 
features  different  from  that  occurring  in  man,  just  as  in  the 
previous  group  the  disease  in  man  differed  typically  from  that 
in  the  animal.  We  consider  here  the  accidental  wound  fevers 
— erysipelas,  septicaemia,  pyaemia,  diphtheria — and  the  most 
serious  of  all  infectious  diseases,  tuberculosis. 

Micrococcus  Erysipelas.  A  small,  round  granule,  which 
grows  in  links,  and  has  no  individual  mobility.  Found  in 
the  connective  tissue  of  the  skin  ;  has  been  cultivated  by 
Fehleisen  in  infusions  of  beef,  peptones  and  gelatine.  Pro- 
duces, when  inoculated,  an  inflammation  of  the  skin,  which 
is  migratory  and  accompanied  by  high  remittent  fever. 
Adjoining  a  healthy  spot  there  may  be  a  zone  moderately  in- 
filtrated with  micrococci,  which,  in  its  turn  is  followed  by  a 
zone  infiltrated  with  small  cells,  in  which  the  micrococci  are  no 


PARASITIC   AND    INFECTIOUS   DISEASES.  225 

longer  visible.  The  infiltration  of  the  micrococci  and  the 
inflammatory  exudation  progress  most  rapidly  in  the  super- 
ficial lymphatic  plexuses  of  the  skin. 

The  microphytes  of  diphtheria,  septicaemia  and  pyaemia  have 
not  as  yet  been  individually  propagated.  The  experiments 
already  made  establish,  however,  that  there  are  many  different 
species  of  decomposition  microphytes,  some  of  which  evoke 
septic  conditions  in  one  class  of  animals,  some  in  another. 
Thus  it  is  probable  that  certain  species  of  decomposition-fungi 
are  dangerous  to  the  human  body.  There  may  be  one  variety 
which  selects  granulating  wounds  and  mucous  membranes 
upon  which  to  produce  diphtheritic  inflammation ;  another 
which,  without  local  inflammation,  passes  directly  from  a  fresh 
wound  into  the  blood  and  creates  a  sudden,  fatal  septicaemia. 
Still  a  third  whose  invasion  is  marked  by  phlegmonous  inflam- 
mation, purulent  infiltrations,  thrombosis,  embolism,  metastatic 
abscesses,  and  violent  remittent  fever  (pyaemia). 

Bacillus  Kochli.  Tubercle  bacillus.  Next  to  the  bacillus 
of  leprosy  the  smallest  of  all  known  bacilli.  Characterized 
by  a  peculiar  investment,  which  can  be  dissolved  by  strong 
alcoholic  solutions.  This  explains  the  difficulty  of  so  coloring 
the  bacillus  (with  the  coloring  matters  at  our  disposal)  as  to 
make  it  accessible  to  microscopical  diagnosis.  It  also  affords 
a  possible  explanation  of  the  great  tenacity  and  diffusion  of 
this  bacillus,  which  thrives  in  every  region  known  to  man. 
It  becomes  mingled  with  the  dust  of  the  atmosphere,  chiefly 
from  the  spittle  of  consumptives  which  has  been  dried  by  the 
sun  and  air.  This  naturally  occurs  more  frequently  in  streets 
than  in  dwelling  houses,  where  the  spittle  is  deposited  in 
cuspidors  and  handkerchiefs.  Thus  a  certain  universality  is 
ensured  to  the  tubercle  fungus,  by  which  it  inhabits  all  the 
abodes  of  man,  chiefly,  of  course,  the  uncleanly  ones. 

The  tubercle  bacillus  is  partial  to  the  moist  inner  surface 
of  the  respiratory  organs,  although  the  deposition  is  not 
effected  with  equal  ease  in  every  case  and  at  every  point. 
The  majority  of  people  are  non-receptive  as  regards  this 
deposition,  and,  when  receptive,  display  many  different  de- 
grees of  susceptibility.  In  some  a  catarrhal  condition  of  the 
bronchial  mucous  membrane  seems  to  pave  the  way  for  the 
deposition  ;  in  many  others,  the  catarrh  must  be  regarded 
as  the  first  result  of  the  deposition.  There  are,  moreover, 
local  favoring  conditions  without  which  no  deposition  can  be 


226  GENERAL    PATHOLOGY. 

made.  It  is  only  in  the  apex  of  the  lung — where  respirations 
are  less  perceptible  and  the  ventilation  is  poor — that  the 
settlement  is  made  (at  least  in  adults)  while  the  remaining 
portions  of  the  lung  are  temporarily  ignored.  Only  particu- 
lar points,  such  as  those  points  where  the  smallest  bronchioles 
merge  into  the  respiratory  parenchyma,  admit  of  the  first 
engrafting,  etc. 

What  then  follows  after  the  tubercle  bacillus  has  gained  a 
firm  footing  in  the  apex  of  the  lung  is  recorded  in  the  patho- 
logical anatomy  of  phthisis  tuberculosa.  I  cannot  again  enter 
into  the  oft-repeated  details  of  this  process.  I  will  merely 
give  the  outline  of  the  elementary  histological  process,  i.  e.,  of 
the  specific  tuberculous  inflammation,  produced  by  the  bacil- 
lus tuberculosus.  The  first  definite  product  produced  by  it  is 
a  cellular  deposition  in  the  form  of  nodes,  ridges  and  other 
irregular-shaped  but  circumscribed  intumescentise  in  the  con- 
'nective  tissue.  The  minutely  nodular  miliary  shape  of  this 
first  product  of  tuberculous  inflammation  is  especially  fre- 
quent, and  so  typical  that  for  a  long  time  the  miliary  tubercle 
was  regarded  as  the  exclusive  product  of  tuberculosis.  As  a 
first  aid  to  diagnosis  the  miliary  tubercle  will  always  be  emi- 
nently useful,  although  it  cannot  be  allowed  to  usurp  the 
monopoly  as  a  specific  product. 

In  an  analysis  of  a  miliary  or  non-miliary,  recent,  tuber- 
culous centre  of  inflammation,  we  cannot  overlook  a  typical 
dissimilarity  of  internal  arrangement.  The  centre  or  axis  of 
the  globular,  or  rather  more  retiforra  structure,  is  composed 
of  large  epithelioid  cells,  having  a  powerfully-refractive,  finely 
granular  protoplasm,  and  numerous  smooth  nuclei  frequently 
arranged  in  pairs.  Further  investigation  shows  almost  always 
in  the  centre  of  these  large  cells  some  specimens  of  the  genu- 
ine giant-cell  with  numerous  peripherally  situated  nuclei 
containing  nucleoli.  Externally  the  epithelioid  cells  are 
surrounded  by  a  broad  zone  of  common  exudate  cells.  Only 
in  the  latter  are  intact  blood  vessels  still  to  be  found,  while 
further  in  they  are  completely  obliterated,  and  cannot  even 
be  filled  by  powerful  injections. 

The  bacillus  Kochii  is  most  apt  to  be  found  in  the  giant- 
cells  already  mentioned.  The  finely-granular  protoplasm  of 
the  latter  contains,  as  a  rule,  several  of  these  delicate  bacilli, 
distributed  apparently  without  any  particular  system.  Bacilli 
are  likewise  found  in  the  free  spaces  between  the  epithelioid 


PARASITIC   AND   INFECTIOUS   DISEASES.  227 

cells,  some  singly,  others  in  groups.  The  general  impression 
gained  is  that  the  invasion  and  growth  of  the  bacillus  has 
produced  (1)  a  circumscribed  inflammation  with  cellular 
exudate,  (2)  a  peculiar  enlargement  of  the  nearest  exudate 
cells  into  epithelioid  structures,  (3)  the  growth  of  some  into 
giant-cells.  It  seems  probable  that  the  formation  of  the  giant- 
cells  is  especially  due  to  the  "  introduction  of  bacilli  into  the 
cell  body." 

We  are  thus,  in  a  measure,  authorized  to  charge  to  the 
account  of  the  bacillus  Kochii  all  the  characteristic  features 
of  tuberculous  inflammation,  from  its  initiation  up  to  its  acme, 
and  are  furthermore  strengthened  in  this  view  by  the  peculiar 
sort  of  retrograde  metamorphosis  which  takes  place  in  the 
tuberculous  inflammatory  products.  This  is  "  cheesy  necrosis," 
which  at  one  time  was  esteemed  as  pathognomonic  of  tuber- 
culosis as  the  miliary  tubercle. 

Cheesy  degeneration  yields,  like  diphtheria,  a  firm,  yellowish- 
white  product,  which,  in  its  later  stages,  after  the  processes  of 
softening  and  dissolution  have  converted  the  original  firm  sub- 
stance into  a  rather  crumbling  or  greasy  consistency,  bears  a 
striking  resemblance  to  certain  varieties  of  cheese. 

The  incipient  cheesy  degeneration  is  apparent -to  the  naked 
eye  as  a  white  cloudiness  of  the  otherwise  more  transparent, 
gray,  inflammatory  product.  Histological  investigation  re- 
veals a  metamorphosis  of  the  cells  into  opaque,  granular,  stiff 
and  indistinctly-outlined  flakes,  in  which  the  application  of 
ordinary  coloring  agents  fails  to  disclose  a  nucleus. 

A  section  frequently  shows  fibrous  cleavage  of  the  entire 
substance.  These  fibres  are  grouped  in  a  circular  manner 
around  certain  points  within  the  cheesy  centre,  which  I  regard 
as  an  unsuccessful  attempt  towards  the  formation  of  granula- 
tion tissue.  The  whole  is,  however,  so  closely  compressed  and 
even  in  the  thinnest  sections  so  opaque,  that  it  is  useless  to 
attempt  a  more  minute  examination. 

A  period  of  inactivity  sets  in  when  cheesy  degeneration  is 
complete,  after  which  further  chemico-physical  metamorphoses 
are  consummated,  which  are  known  as  "softening  of  the 
cheesy  centre."  The  coagulated  albuminous  bodies  become, 
as  it  were,  digested,  and  would  gradually  dissolve,  like  the 
large,  cheesy  nodules  of  the  brain,  into  a  clear,  greenish- 
yellow  liquid,  were  this  process  not  usually  forestalled  by  a 
rupture  externally  of  the  centre  of  softening,  and  the  dis- 


228  GENERAL    PATHOLOGY. 

charge  of  the  partly-decomposed  matter.  These  partly- 
decomposed,  crumbling,  pulpy  masses  are,  assuredly,  very 
similar  to  cheese,  but,  nevertheless,  are  not  particularly  char- 
acteristic, since  similar  products  result  from  the  drying-up  of 
pus  contained  in  abscesses. 

The  lung  is  the  favorite  seat  of  Koch's  bacillus.  We  find 
here,  as  a  result  of  the  tuberculous  inflammation,  cheesy 
change  and  softening — that  first  a  single  lobule  is  affected  ; 
later,  however,  the  process  spreads,  so  that,  finally,  entire  lobes 
of  the  lung  die  and  are  cast  off.  The  name  Phthisis  is,  ac- 
cordingly, most  suitable. 

The  disease  is  propagated  in  various  ways  from  its  starting 
point  in  the  lung.  The  spittle  of  consumptives,  being  full  of 
bacilli,  constantly  infects  new  portions  of  the  mucous  tract, 
spreading  along  the  surface  and  operating  most  powerfully 
upon  spots  into  which  it  is  rubbed  and  pressed  with  a  certain 
mechanical  force,  or  where  the  epithelial  protection  is  less 
perfect.  Thus,  in  the  passage  through  the  larynx,  the  edges 
of  the  true  vocal  cords,  the  vocal  processes  and  the  folds  of 
the  posterior  rim  of  the  glottis,  are  favorite  seats  of  tuber- 
culous ulceration.  Swallowed  spittle  occasions  tuberculous 
ulceration  of-  the  lymphatic  glands  in  the  small  and  large  in- 
testines, the  result  being  the  so-called  intestinal  consumption. 
The  nose,  tongue,  pharynx  and  stomach  may  in  this  way  be 
infected,  although  this  is  rare. 

Another  manner  in  which  the  poison  and  the  tuberculous 
inflammation  may  be  diffused  is  through  the  lymph  paths  of 
the  lung.  The  tubercle  fungus  causes  here  a  specific  lymph- 
angitis, which  to  the  naked  eye  resembles  an  eruption  of  many 
closely  aggregated  miliary  tubercles.  Tuberculosis  is  con- 
veyed through  the  lymph  paths  to  the  bronchial  lymphatics 
on  the  one  side,  and  to  the  surface  of  the  pleura  on  the  other. 
The  lymphatic  glands  swell  and  undergo  cheesy  degeneration  ; 
the  phenomena  in  the  pleura  are  more  complicated. 

There  are  cases  where  the  eruption  of  miliary  tubercles 
gives  rise  to  a  circumscribed  inflammation  and  agglutination 
of  the  two  pleura.  Such  a  permanent  contact  is  wont  to 
produce  an  infection  of  the  costal  pleura  as  well.  The  ad- 
hering parts,  when  separated  by  the  knife,  show  an  equal 
extent  of  both  surfaces  covered  with  miliary  tubercles,  and 
even  a  few  nodes  in  the  adjacent  efferent  lymphatics. 

In  other  instances  the  pleurisy  itself  attains  greater  inten- 


PARASITIC   AND   INFECTIOUS   DISEASES.  229 

sity  and  diffusion.  Consumptives  are,  as  we  know,  much 
inclined  to  pleurisy.  Both  adhesive  and  purulent  forms  are 
observed,  but  it  is  at  present  difficult  to  decide  in  what  degree 
the  tubercle  fungus  is  active  as  a  causative  agent  in  the 
pleurisy  of  consumptives,  and  in  what  degree  the  collateral 
hyperaemia  of  the  pleural  blood  vessels,  which  is  a  necessary 
result  of  the  internal  disturbances  of  the  lung,  is  concerned. 

The  bacilli  may  also  penetrate  into  the  blood  vessels  of  the 
lung  and  thus  into  the  blood  vessels  of  the  entire  body.  It  is 
not  alone  in  the  pulmonary  veins  that  their  depositions  are 
found;  the  eruption  ofmiliary  tubercles  throughout  the  whole 
body  testify  to  the  widespread  infection.  The  disseminated 
tubercles  are  especially  abundant  in  the  liver,  serous  mem- 
branes and  choroid  coat  of  the  eye.  Still  there  are  many  reasons 
why  we  should  not  associate  general  miliary  tuberculosis 
too  intimately  with  pulmonary  consumption.  It  by  no  means 
runs  a  regular  course.  There  are,  on  the  contrary,  numbers 
of  cases  where  pulmonary  tuberculosis  is  not  productive  of 
tuberculosis  of  the  bronchial  lymphatic  glands,  and  still  more 
numerous  instances  where  it  terminates  in  a  cheesy  degener- 
ation of  the  lymphatic  glands,  and  where  general  infection 
does  not  occur  because  of  the  obstruction  of  the  blood  lymph- 
atics. Let  us  not  forget  that  the  usual  picture  of  tuberculous 
inflammation  shows  the  specific  products  surrounded  by  a 
circle  of  young  granulation  tissue  which  contains  blood  vessels, 
and  might  upon  occasion  be  utilized  to  separate  the  cheesy 
masses.  This  separation  may  be  brought  about  by  suppura- 
tion and  discharge,  or  by  encapsulation  and  toleration  of  the 
dead  parts.  In  any  event  it  intimates  the  possible  emanci- 
pation of  the  organism  from  the  invading  microphytes,  and 
allows  us  in  many  cases  to  regard  consumption  of  the  lungs  as 
a  local  and  therefore  curable  disease. 

Nevertheless,  it  can  hardly  be  doubted  that  consumption  of 
the  lungs  produces  a  decided  change  in  the  whole  organism, 
which,  among  other  things,  is  seen  in  the  predisposition 
towards  the  disease  found  in  the  progeny  of  consumptives.  In 
this  sense  tuberculosis  may  be  called  an  hereditary  disease. 
What  it  is  that  is  transmitted  from  parent  to  child  no  one  has 
as  yet  determined. 

The  morbid  tendency  of  individuals  with  inherited  "  scrof- 
ulous "  diathesis  is  noticeable  in  their  attitude  towards 
inflammatory  irritants.  Very  trifling  inflammatory  causes, 


230  GENERAL   PATHOLOGY. 

which  are  easily  overcome  by  a  healthy  man,  produce  in 
them  a  lasting  impression.  Poor  blood  and  a  weak-walled 
vascular  system  are  effective  allies.  Scrofulous  inflamma- 
tions begin,  consequently,  as  a  rule,  with  a  hypersemia,  in  the 
first  rush  of  which  the  veins  and  capillaries  are  excessively 
dilated.  Its  further  course  does  not  correspond  to  this 
stormy  commencement.  The  blood  current  is  retarded  in  the 
relaxed  and  therefore  dilated  blood  vessels.  In  following  the 
course  with  the  naked  eye,  as  maybe  done  in  the  conjunctiva, 
we  note,  indeed,  an  accumulation  of  blood  in  the  blood 
vessels,  accompanied  by  convolutions  of  the  smallest  veins, 
etc.,  but  the  blood  interchange  is  sluggish,  and  the  blood,  in 
consequence,  is  dark,  with  a  bluish  tinge.  Now  follows  the 
exudation,  or  rather  the  equivalent  of  such.  There  is  no 
rapid  outwandering  of  colorless  blood  corpuscles  from  the 
vessels,  no  rapid  and  abundant  secretion  or  suppuration.  A 
cellular  exudate  is  furnished,  it  is  true,  but  the  exudatory 
current  is  weak.  The  cells  scarcely  advance  beyond  the 
limits  of  the  blood  vessels.  They  remain  in  the  perivascular 
connective  tissue,  producing  thus  a  parenchymatous  infiltrate, 
which,  at  best,  disappears  but  slowly.  The  superficial  secre- 
tions are  semi-fluid  and  dry  up  rapidly. 

Such  inflammations  threaten  principally  the  outer  skin, 
mucous  membranes,  and  joints  of  scrofulous  persons,  those 
points,  in  fine,  which  are  most  frequently  subjected  to  trifling 
irritations  of  a  mechanical  or  chemical  nature.  Investigation 
has  not,  as  yet,  been  able  to  establish  whether  Koch's  bacillus 
is  concerned  in  the  origin  of  these  inflammations.  It  has, 
however,  been  proved  that  it  exists  in  the  secondary  products 
of  inflammation,  which  have  always  been  considered  as  the 
most  important,  if  not  the  pathognomonic  products  of 
scrofula.  These  are  the  scrofulous  swellings  of  the  lym- 
phatic glands. 

Even  before  the  discovery  of  the  bacillus,  the  hyperplastic/ 
cheesy  degenerations,  which  are  so  often  found  in  scrofula  in 
the  lymphatic  glands  of  the  neck,  and  occasionally  in  other 
regions,  were  regarded  as  tuberculous  inflammations.  The 
positive  certainty  which  we  now  possess  serves  as  an  important 
key  to  the  understanding  of  numerous  other  tuberculous  phe- 
nomena. 

It  is  possible,  and,  indeed,  often  occurs,  that  the  cheesy 
glands  become  either  permanently  encapsulated  or  are  thrown 


PARASITIC   AND   INFECTIOUS   DISEASES.  231 

off  by  periadenitic  suppuration,  so  that  the  organism  is  pre- 
served from  the  pernicious  influence  of  the  poison  contained 
in  these  glands.  On  the  other  hand,  it  is  plain  that  the  body 
is  in  danger  of  infection  with  tubercle  bacilli  and  of  an  out- 
break of  the  so-called  acute  miliary  tuberculosis.  Thus  it  is 
that  the  latter  extremely  dangerous  general  disease,  which, 
after  weeks  of  violent  fever,  results  in  death,  is  oftener  met 
with  in  persons  of  a  scrofulous  diathesis  than  in  non-scrofulous 
consumptives.  There  is,  to  be  sure,  a  frequent  commingling 
of  the  phenomena  of  scrofula  and  of  localized  tuberculosis 
(phthisis),  chiefly  in  cases  where  the  seat  of  a  tubercular 
phthisis  is  found,  not  in  the  lung,  but  in  the  bones,  brain, 
kidneys,  testicle,  uro-genital  mucous  membranes,  etc. 

The  manner  in  which  these  varieties  are  introduced  is  as 
yet  unknown.  Many  points  in  the  foregoing  description  will 
doubtless  be  subjected  in  future  to  more  careful  study,  and 
brought  into  more  correct  relations  to  the  whole.  No  one 
can  be  more  ready  than  myself  to  acknowledge  the  provisory 
nature  of  these  statements. 

Tuberculosis  is  also  transmissible  to  animals.  In  cattle  it 
appears  as  murrain.  Rabbits  and  guinea  pigs  may  be  ren- 
dered tuberculous  by  inoculation  with  the  tuberculous  pro- 
ducts of  man.  In  from  four  to  six  weeks  the  inoculated 
tuberculosis  develops  into  a  fatal  disease.  Sections  show  the 
different  organs  filled  with  small-celled,  yellowish-white  tuber- 
cles and  infiltrations  in  the  act  of  undergoing  cheesy  change. 

(d)  The  last  group  of  contagious  diseases  is  the  exclusive 
property  of  the  human  race.  The  respective  microphytes 
appear  to  disdain  any  other  soil,  and  require  for  propagation 
a  direct  transmission  from  man  to  man.  They  are  transmitted 
in  smallpox,  scarlet  fever  and  measles,  by  inspiration,  in 
syphilis  by  vaccination,  in  hooping-cough  and  other  conta- 
gious catarrhs  (gonorrhoea)  by  the  catarrhal  secretion  reaching 
the  mucous  membranes  of  healthy  individuals.  Leprosy  must 
be  classed  by  itself. 

The  poison  of  scarlet  fever  reaches  the  human  organism  by 
inspiration.  An  inflammatory  irritation  of  the  isthmus  fau- 
cium  and  pharynx,  which  is  often  very  severe,  seems  to  point 
to  the  local  effect  of  the  fungus.  This  is  followed  by  its 
reception  into  the  blood,  and  after  a  period  of  incubation, 
lasting  from  from  four  to  seven  days,  by  very^high  fever  and 


232  GENERAL   PATHOLOGY. 

rapid  pulse.  A  diffuse  but  intense  redness  breaks  out  on  the 
skin,  with  which  is  associated  a  premature  loss  of  the  horny 
layer  of  the  epidermis.  This  is  the  most  infectious  period. 
It  appears,  therefore,  that  the  fungi,  having  been  deposited  in 
the  skin,  are  freed  with  the  desquamative  process.  The  rather 
frequent  accompaniment  of  renal  inflammation  indicates  an 
attempt  of  this  organ  to  secrete  the  poison.  One  attack  usually 
provides  against  a  second. 

The  poison  of  measles  is  also  breathed  in.  In  about  thirteen 
days  after  reaching  the  blood  it  produces  moderately  high 
fever,  whose  defervescence  is  marked  by  a  characteristic  erup- 
tion. First  the  neck  and  temples,  then  the  breast  and  entire 
body,  are  covered  with  red  spots,  which  are  often  slightly 
raised,  and  feel  like  nodes.  Some  days  later  desquamation 
ensues,  at  which  time  the  danger  of  infection  is  greatest,  which 
would  indicate  a  scattering  of  the  poison  from  the  cuticle. 
In  exceptional  cases  there  is  marked  inflammatory  irritation 
of  the  channels  of  entrance,  the  mucous  membrane  of  the 
nose  and  the  bronchial  tubes.  The  first  attack  does  not 
always  afford  protection  against  a  second.  Some  persons  have 
had  measles  three  times. 

What  we  now  regard  as  the  smallpox  microphyte  is  a 
peculiar  elongated  microphyte  found  in  the  smallpox  pustule. 
Whether  this  supposition  be  correct  or  not,  remains  to  be 
established  by  future — and  we  trust  not  far  distant — re- 
search. 

The  poison  of  smallpox  is  communicated  by  inhalation  of 
infected  air.  After  ten  to  thirteen  days  a  chill  initiates  the 
fever,  and  three  days  later  a  cutaneous  eruption  makes  its 
appearance,  with  a  scarcely  perceptible  subsidence  of  the 
fever.  The  anatomical  characteristics  of  this  eruption  are 
discussed  at  length  in  my  Manual  of  Pathological  Anatomy. 
Bright  red  spots,  appearing  first  on  the  head,  then  on  the 
other  portions  of  the  body,  are  superseded  on  the  fifth  day 
after  the  chill  by  raised  nodules,  on  the  sixth  by  vesicles  filled 
with  a  clear  liquid  (the  smallpox  lymph).  Each  vesicle  is 
subdivided  into  compartments,  because  the  exudate  does  not 
remove  the  cells  of  the  epidermis  in  toto,  but  scatters  them 
into  layers  and  lamellae.  On  the  ninth  day  the  vesicle  is  re- 
placed by  a  pustule,  and  to  the  clear  liquid  is  added  numbers 
of  out-wandered  pus  corpuscles.  The  straw-colored  pustule 
with  its  dark  red  halo  presents  a  most  characteristic  appear- 


PARASITIC   AND   INFECTIOUS   DISEASES.  233 

ance.  About  the  twelfth  day  the  pustules  begin  to  burst  and 
dry  up.  This  process  is  accompanied  by  excessive  itching, 
which  tempts  the  patient  to  scratch  himself  and  thus  deepen 
the  scars  which  subsequently  form  at  the  seats  of  this  purely 
superficial  pus  secretion. 

The  intensity  and  extent  of  this  eruption  determines  in 
part  the  risk  to  the  life  of  the  patient.  The  more  extended 
the  ulceration  (variola  confluens),  the  stronger  the  alteration 
in  the  vascular  wall  (variola  hsemorrhagica),  the  more  serious 
the  prognosis.  Complications  and  secondary  affections  of  the 
nervous  system,  eyes,  lungs,  etc.,  must  also  be  considered. 

The  immunity  afforded  by  an  attack  of  smallpox  is  most 
complete  and  can,  fortunately,  be  obtained  by  inoculation  with 
cowpox  (vaccine),  so  that  those  who  have  been  inoculated  with 
cow-virus  are  either  entirely  exempt  from  genuine  smallpox 
or  experience  it  in  a  mild  form. 

In  spite  of  the  most  clever  investigations,  we  have  not  been 
able  to  establish  the  vegetable  origin  of  syphilis.  It  seems  to 
be  a  slowly- vegetating  microphyte,  firmly  attached  to  its  native 
soil,  with  some  portion  of  which  it  can  alone  be  transferred, 
i.  e.,  inoculated  into,  another  person.  This  transpires  most 
frequently  through  the  intimate  contact  of  the  sexual  organs 
in  coition.  The  insignificant  lesions  of  the  skin  thus  caused 
afford  an  entrance  to  the  syphilitic  poison.  A  slight  redness 
at  the  point  of  entrance,  which  shows  itself  within  the  first  few 
days,  and  then  disappears,  is  generally  overlooked.  The  poison, 
however,  increases  slowly,  at  the  inoculated  spot,  whence  it 
spreads,  and  is  carried  by  the  lymphatics,  first  of  all,  into  the 
next  lymphatic  glands.  It  is  probable  that  even  at  this  juncture 
certain  particles  of  poison  pass  from  the  lymphatic  glands  into 
the  blood.  Still,  the  greater  part  remains  temporarily  at  the 
vaccinated  spot  and  in  the  adjacent  lymphatic  glands.  After 
the  space  of  about  twenty-eight  days,  it  produces  a  powerful 
irritation  of  the  tissues,  resulting  in  a  small-celled,  firm  and 
thick  infiltration  of  the  connective  tissue  around  the  point  of 
inoculation,  the  so-called  initial  sclerosis,  and  a  similar 
swelling  and  induration  of  the  local  lymphatic  glands.  The 
sclerosis  develops  into  the  hard  or  Hunterian  chancre;  the 
swollen  inguinal  glands  remain  thus  for  a  long  time  without 
advancing  to  further  development  (indolent  bubo). 

Four  weeks  having  again  elapsed,  the  infection  of  the  gen- 
eral organism  has  advanced  sufficiently  to  demand  more 
16 


234  GENERAL    PATHOLOGY. 

extensive  reaction  against  the  poison.  Side  by  side  with  the 
often  very  decided  eruptive  fever,  we  find  surface  inflamma- 
tions of  the  cuticle  and  mucous  membranes.  Every  variety 
of  exanthema  has  been  observed  on  the  syphilitic  skin. 
There  are  erythematous,  papular,  pustular,  squamous  syphi- 
lides  ;  the  hair  frequently  falls  out. 

In  proportion  as  the  disease  runs  an  uninterrupted  course, 
the  deeper  are  the  parts  implicated  in  the  specific  processes  of 
inflammation ;  first  of  all  the  eye  (Iritis  syphilitica)  and  the 
testicle,  then  the  brain,  osseous  system,  liver,  and  other  organs. 
.  Secondary  syphilis  produces  a  peculiar  variety  of  tissue, 
known,  on  account  of  its  soft,  elastic  consistency,  as  gumma. 
It  is  at  first  reddish  and  vascular,  afterwards  whitish,  and 
forms  round  nodes,  which  average  the  size  of  a  pea,  and  are 
closely  aggregated  in  groups.  The  microscope  shows  good- 
sized,  closely-aggregated  granulation  cells,  which  are  under- 
going in  places  fatty  degeneration.  These  gummata  are 
found,  not  only  in  the  deeper-seated  organs  mentioned,  but 
also  in  the  skin  and  mucous  membranes.  Here  they  are 
located  in  the  connective  tissue,  and  form  nodular  swellings, 
which  afterwards  soften  and  are  discharged,  occasioning  wide- 
spread destruction. 

The  syphilitic  virus  must  be  destroyed  in  the  body,  for  it 
cannot  be  eliminated.  In  no  place  can  it  overstep  the  epithelial 
boundary  of  the  body,  either  from  within  outwards,  or  from 
without  inwards.  This  is  manifested  in  certain  features 
relating  to  the  hereditary  transmission  of  the  disease.  The 
semen  of  a  syphilitic  man,  the  ovum  of  a  syphilitic  mother, 
transmits  syphilis  to  their  posterity.  When,  however, 
syphilis  has  been  acquired  by  the  mother  towards  the  end  of 
pregnancy,  the  disease  is  not  transmitted  to  the  child.  It 
would  seem  to  be  impossible  for  the  poison  to  pass  through 
the  double  capillary  wall  and  also  the  thick  epithelial  layer 
of  the  placeutal  cells. 

Therapeutists  are  also  forced  to  acknowledge  this  factor. 
Luckily  we  possess  in  mercury  a  remedy  which  is  admirably 
adapted  to  render  the  syphilitic  virus  in  the  organic  juices 
innocuous. 

Microphyton  Gonococcus.  The  purulent  secretion  of  ureth- 
ritis  and  elythritis  gonorrhoica,  when  treated  with  proper 
staining  fluids,  reveals  a  remarkable  fact,  viz.,  that  a  portion 
of  its  pus  corpuscles  contain,  in  addition  to  the  nucleus,  a 


PARASITIC   AND   INFECTIOUS   DISEASES.  235 

group  of  good-sized  micrococci,  ranging  in  number  from  4-20. 
The  same  are  also  found  in  the  free  secretion  mingled  with 
the  pus  corpuscles. 

It  thus  appears  that  in  gonorrhoea,  gonococci  are  carried  to 
the  healthy  mucous  membrane ;  that  they  proliferate  rapidly  in 
a  few  days'  time  and  penetrate  through  the  investing  epi- 
thelium into  the  deeper  layers  of  the  mucous  membrane. 
Having  in  this  manner  reached  the  vascular  and  nervous 
parenchyma  of  the  mucous  membrane,  they  produce  an  in- 
flammation, and  the  gonococci  are  taken  up  into  the  paren- 
chyma of  the  colorless  blood  corpuscles.  They  thus  pursue 
their  way,  some  of  them  reaching  the  surface  in  company  with 
the  purulent  secretion,  some  penetrating  through  the  lymph- 
paths  into  the  interior  of  the  body.  Now,  although  this  secre- 
tion brings  about  a  rejection  of  the  poison  from  the  body, 
there  is  danger  that  the  process  of  resorption  may  infect  the 
general  organism.  There  was  formerly  much  talk  of  gonor- 
rhoeal  metastases ;  at  present  those  statements  require  re- 
vision. 

Bacillus  Leprce.  Although  the  artificial  culture  of  the 
bacillus  leprse  has  not  yet  been  successful,  nor  has  its  patho- 
genous nature  been  proved  by  inoculation ;  it  does  not  seem 
to  me  to  admit  of  a  doubt  that  the  bacillus  discovered  by 
Armauer  Hansen  is  the  vegetable  originator  of  leprosy,  or 
elephantiasis  grsecorum. 

In  leprosy  we  are  confronted  by  a  disease  whose  character 
has  been  greatly  altered  in  the  course  of  centuries.  A  thous- 
and years  ago  it  was  the  plague  of  Europe  and  the  countries 
bordering  on  the  Mediterranean.  The  slightest  touch  was 
contagion,  and  it  was  necessary  to  separate  lepers  from  the 
rest  of  the  world,  and  keep  them,  until  their  death,  in  lazarettos. 
Now  it  is  confined  to  a  few  territories,  chiefly  on  the  coasts  of 
Norway,  Sweden,  Italy  and  Asia.  It  is  not  that  the  disease 
itself  is  less  frightful  and  deforming  in  its  effects  than  at  the 
period  of  its  greatest  diffusion,  but  that  it  is  no  longer  equally 
contagious.  The  cases  are  carefully  noted  and  may  be  counted, 
in  which  there  is  evidence  of  contagion.  Only  the  hereditary 
transmission  of  leprosy  is  held  to-day  to  be  possible,  and,  in 
most  cases  probable.  It,  furthermore,  appears  that  the  nature 
of  the  bacillus  is  changed,  just  as  similar  gradations  have 
been  observed  in  the  quality  of  syphilitic  virus. 

Leprosy  is   pre-eminently  a  cutaneous  disease.     Ked  and 


236  GENERAL    PATHOLOGY. 

swollen  blotches  first  appear  on  the  least  protected  and  most 
exposed  surfaces  of  the  body.  Later  there  appears  a  srnall- 
celled  infiltration  in  the  shape  of  nodes  and  boils,  which  first 
attack  the  most  prominent  points — the  nose,  superciliary 
ridges,  auricle,  chin,  malar  processes,  lips  and  knuckles.  It  is 
evident  that  the  bacillus  leprse  is  concerned  with  the  external 
injuries,  and  has  effected  a  settlement  there.  Delicate  sections 
of  leprous  skin  show  countless,  short,  tiny  bacilli,  which  are 
the  smallest  known  pathogenetic  bacilli.  They  lie  in  groups 
in  the  larger  cells  of  the  leprous  nodes,  and  are  likewise  found 
together  with  the  cells  in  the  tissues. 

The  peripheral  nervous  system  is,  next  to  the  skin,  the  fa- 
vorite seat  of  leprosy.  Knotty  and  cord-like  infiltrations  of 
the  nerve  sheaths  cause  an  insensibility  of  the  skin  (lepra 
ansesthetica),  and  a  tendency  to  partial  gangrene,  such  as  we 
have  seen  in  tropho-neu  roses. 

This  short  sketch  will  not  permit  of  a  more  extended  de- 
scription of  the  phenomena  of  leprosy.  My  aim  has  merely 
been  to  furnish  the  reader  with  a  sufficiently  clear  justification 
of  my  plan  of  etiological  division  of  diseases. 

III.  DEFECTIVE  DEVELOPMENT  AND  GROWTH. 
DISEASES  OF  EVOLUTION. 

Preliminary  Remarks. 

Although  there  is  no  doubt  that  disturbances  of  develop- 
ment and  growth  must  be  regarded  as  a  special  group  in  our 
etiologically-based  division  of  diseases,  we  encounter  difficulties 
when  we  attempt  to  point  out  those  symptoms  which  may  be 
regarded  as  universally  characteristic.  We  can  only  say  that 
the  diseases  of  this  group  are  frequently  traceable  to  circum- 
stances and  conditions  of  the  parental  organisms  whence  the 
diseased  bodies  descended,  and  that  we  have  to  do  with  con- 
genital, or  rather,  with  inherited  diseases. 

This  "hereditary"  nature  of  a  disease  is  manifested  in  vari- 
ous ways,  but  most  clearly  in  cases  where  a  defect  of  the  father 
or  mother  is  repeated  identically  in  the  child. 

It  is  highly  probable  that  in  some  disposition  of  the  minutest 
and  most  imperceptible  elements  of  the  ovum  and  spermatic 
fluid  there  exists  the  idea  of  the  whole,  which,  under  certain 
conditions  appears  as  a  local  and  individual  plan  of  develop- 
ment. In  fecundation,  when  the  ovum  and  the  spermatic  fluid 


DEFECTIVE    DEVELOPMENT   AND   GROWTH.  237 

are  brought  into  contact  with  each  other,  both  bring  with 
them  the  same  generic  plan  of  development,  although  the  indi- 
vidual characteristics  of  each  are  different,  and  in  fact  often 
widely  divergent.  I  will  not  allude  here  to  the  peculiarities  of 
race,  to  the  conformation  of  the  cranium  and  face,  to  the  color 
of  the  skin,  and  the  peculiar  growth  of  the  hair,  but  merely 
call  attention  to  the  large  number  of  actual  pathological  ap- 
pearances, which  give  an  individual  stamp  to  the  generic  plan 
of  development,  as  existing  both  in  the  ovum  and  in  the  sper- 
matic fluid.  The  most  varied  diseases  of  organs,  acquired  as 
well  as  inherited,  produce  in  the  generic  development  of  both 
male  and  female  germinal  material,  modifications  which  exert 
an  influence  upon  the  development  of  the  children.  Such 
inherited  diseases  may  be:  an  hydrocephalic  brain,  a  phthis- 
ical lung,  tumors  and  defects  of  all  kinds ;  also  the  lack  or 
excess  of  susceptibility  in  certain  organs  towards  physiological 
irritation,  which  must  depend  upon  a  certain  anatomical  qual- 
ity of  the  same.  In  general  we  must  regard  the  modifications 
produced  by  the  diseased  condition  of  the  parents  as  local 
weaknesses,  more  seldom  as  actual  paralyses  of  the  principle 
of  development,  which  have  given  rise  to  corresponding  weak 
spots,  i.  e.,  gaps,  in  the  individual  plan  of  development. 

If  both  father  and  mother  should  chance  to  have  the  same 
weak  spot,  as  often  happens  in  marriages  between  near  rela- 
tions, the  danger  is  apparent  that  the  development  of  the  child 
in  this  particular  locality  will  be  very  defective.  This  is  sub- 
stantiated by  the  well  known  deterioration  of  the  children  of 
such  unions. 

On  the  other  hand,  the  weak  spots  in  one  parent  may  be 
neutralized  by  corresponding  vigor  in  the  other,  and  a  per- 
fectly healthy  child  may  be  born  of  two  partially  diseased 
parents. 

Inherited  diseases  show,  however,  that  this  is  not  a  mere 
matter  of  addition  or  substraction.  On  the  contrary,  the 
child  selects — as  in  the  configuration  of  the  face,  nose,  eyes, 
mouth — one  organ  from  the  father,  another  from  the  mother, 
and  receives  into  the  bargain  the  weak  spots,  which  are,  of 
course,  often  modified  by  the  opposed  plans  of  development. 

It  is  much  more  difficult  to  understand  why  perfectly 
healthy  parents  should  give  birth  to  children  who  are  afflicted 
successively  with  the  same  defect.  As  most  of  these  cases  are 
malformed,  i,  e.,  plus  or  minus  certain  members,  we  are  led  to 


238  GENERAL    PATHOLOGY. 

the  conclusion  that  the  combined  individual  plans  of  develop- 
ment have  exerted  a  harmful  influence  upon  the  generic  plan. 

It  often  occurs  that  inherited  deformities  are  absent  from 
one  or  two  generations,  but  re-appear  in  the  third.  In  such 
cases  it  is  astonishing  to  note  the  enormous  tenacity  with 
which  the  protoplasm  retains  and  is  able  to  repeat  a  series  of 
processes  which  it  has  once  experienced.  I  am,  however, 
unable  to  agree  with  those  who  characterize  certain  human 
anomalies  as  monkey  skulls,  monkey  hair,  monkey  thumbs, 
monkey  shanks,  and  thus  trace  the  impression  of  the  proto- 
plasm backwards  into  the  Darwin  age  of  human  development. 

Before  proceeding  to  individual  consideration  we  must 
somewhat  limit  our  territory  of  disease.  It  is  necessary  to 
exclude  on  the  one  hand  inherited  infectious  diseases,  es- 
pecially hereditary  syphilis,  where  the  child  receives  from  his 
parents  a  certain  principal  of  syphilitic  poison,  from  which  it 
generally  in  a  short  space  of  time  derives  abundant  interest ; 
on  the  other  hand,  congenital  but  not  inherited  pathological 
conditions,  which  arise  from  iutra-uterine  diseases  of  organs, 
especially  traumatic  and  embolic  inflammations.  Unfortu- 
nately, this  latter  group  cannot,  on  account  of  insufficient 
criteria,  be  separated  from  true  defects  in  growth,  and  must, 
therefore,  be  considered  conjointly.  We  distinguish  them 
according  to  the  period  of  time  in  which  the  disturbance  of 
development  manifests  itself: — 

(1)  Defective  arrangement  of  the  blastoderm. 

(2)  Defects  of  intra-uterine  development. 

(3)  Defects  of  extra-uterine  development,  or  during  growth. 

1.    DEFECTIVE   ARRANGEMENT   OP   THE   BLASTODERM. 

(Monstrosities.) 

We  have  now  to  consider  that  first  appearance  of  the  primi- 
tive trace  in  the  area  pellucida  of  the  germinal  vesicle,  which 
denotes  the  commencement  of  foetal  development.  If  there 
be  but  one  primitive  trace  it  is  difficult  to  see  how  its  deposi- 
tion can  effect  a  disturbance  in  development.  It  is  quite 
another  thing  when  there  are  two  embryos  in  the  same  area 
pellucida.  Twins  are  occasionally  found  in  the  same  chorion, 
which  proves  that  they  must  have  been  developed  from  one 
egg.  It  seems  at  least  possible  that  two  primitive  traces  can 
be  disposed  in  the  area  pellucida  in  such  a  manner  as  to 


DEFECTIVE    DEVELOPMENT   AND   GROWTH.  239 

prevent  mutual  disturbances  in  the  development  of  the  two 
embryos.  Still  it  is  also  possible  that  this  favorable  result  can 
only  be  attained  in  an  unusually  large  area  pellucida,  for  we 
learn  from  observation  of  numerous  monstrosities  that  in  all 
the  various  dispositions  of  two  embryos  in  the  same  area 
pellucida  there  is  occasionally  a  fusing  together  of  the 
embryos,  and  eo  ipso  a  corresponding  disturbance  in  develop- 
ment. Basing  upon  the  fact  that  every  primitive  trace  is  as  a 
radius  to  the  surrounding  border  of  the  area  opaca,  let  us 
consider  one  primitive  trace  as. remaining  stationary,  while 
the  other  revolves  around  in  the  area  opaca ;  thus,  we  shall 
obtain  in  turn  the  different  pictures  of  deformities. 

It  is  most  commonly  the  case  that  both  embryonic  implant- 
ations are  opposed  to  each  other  in  the  same  meridian,  head 
to  head.  In  this  position,  fusions  (Pagationes)  between  the 
embryos  in  the  median  line  occur.  These  fusions  vary  in 
locality  and  in  the  time  of  their  occurrence,  thus  inducing 
different  grades  of  disturbance  of  development. 

The  more  the  ova  are  left  to  themselves  the  more  indepen- 
dent do  they  become  of  each  other,  hence  twins  are  often 
found  attached  to  each  other  only  at  a  certain  point;  for 
instance,  by  the  brain  (Cephalopages),  by  the  buttocks  (Pygo- 
pages),  by  the  sternum  (Xiphopages),  or  by  the  umbilicus 
(Omphalopages).  Had  the  formative  material  of  the  area 
been  a  little  more  abundant  true  twins  might  possibly  have 
been  born.  In  the  so-called  "  janus  formation  "  we  encounter  a 
grave  disturbance  of  development.  Here  are  two  distinct 
bodies  joined  together  by  an  enormous  head  with  two  faces. 
In  these  cases,  without  doubt,  there  was  a  union  of  the  two 
axes  (chorda  dorsales)  at  their  anterior  extremity,  at  the  so- 
called  sell*  turcicse,  so  that  there  was  no  opportunity  for  the 
union  of  the  corresponding  halves  of  the  head.  There  was, 
however,  nothing  to  prevent  the  left  half  of  the  head  of  one 
embryo  from  uniting  with  the  right  half  of  the  head  of  the 
other,  to  form  a  joint  face.  All  double  faces  in  janus  forma- 
tions are  composed  partly  of  one,  partly  of  the  other  foetus. 
A  preponderating  side  in  one  of  these  common  faces  is  proba- 
bly due  to  an  inexact  approximation  of  the  axes,  leading  to 
such  a  diminution  in  the  size  of  one  of  the  faces  that,  as  a  rule, 
only  the  ears  remain  (Synotus). 

Thoracodidymus  is  a  monstrosity  in  which  twins  are  united 
by  the  thorax. 


240  GENERAL   PATHOLOGY. 

Gastro-  and  hypogastrodidymus  are  monstrosities  in  which 
twins  are  united  by  the  abdomen. 

Should,  however,  the  second  primitive  trace,  instead  of 
being  diametrically  opposed,  assume  a  more  diagonal  position, 
there  result  lateral  fusions.  In  both  diprosopus  and  janus 
monsters  the  embryonic  axes  meet  at  their  anterior  extremity. 
Hence  we  have  in  diprosopus  also  two  distinct  bodies  and  one 
enormous  head,  but  the  two  faces  arranged  side  by  side.  The 
two  ears  nearest  each  other  are  often  absent,  the  two  nearest 
eyes  converge  often  into  a  single  eye  of  considerable  size.  A 
perfectly  symmetrical  one-sided  fusion,  mesodidymus,  is  said 
to  be  found  in  fishes,  the  right  half  of  the  body  of  one  being 
very  slightly  connected  with  the  left  half  of  the  body  of  the 
other.  This  fusion  has  never  been  observed  in  man.  On 
the  other  hand,  we  very  often  find  remarkable  duplications  of 
the  upper  part  of  the  body  (Anadidymus),  in  which  a  single 
lower  extremity  supports  two  separate  heads  (Dicephalus)  or 
two  distinct  trunks  (Dicormus).  All  possible  intermediary 
forms  can  be  considered  under  the  latter  head.  Their  origin 
can  only  be  traced  to  the  fact  that  the  corresponding  primitive 
traces  lay  head  to  head  and  close  to  each  other,  while  their 
pedal  extremities  lengthened  towards  the  same  point  on  the 
radius  of  the  area  pellucida.  The  two  lines  then  united — in 
proportion  to  their  original  approximation — to  form  a  single 
primitive  trace. 

A  special  group  of  double  formations  results  when,  as  it 
not  rarely  occurs,  one  of  the  two  embryos  attains  full  develop- 
ment, while  the  other  is  more  and  more  stunted  in  its  growth. 
The  former  go  by  the  name  of  autosites,  the  latter  parasites. 
They  are  also  called  foetus  in  fcetu. 

It  is  well  known  that  even  in  completely  developed  twins, 
one  may  be  comparatively  robust,  while  the  other  is  small 
and  weakly.  It  is  a  mistaken  idea  to  consider  the  smallest 
twin  the  youngest,  and  to  explain  it  on  the  ground  of  a  second 
impregnation. 

Many  remarkable  things  occur  when  unequal  twins  are 
united  to  form  a  double  monster.  Epicome  is  that  variety  in 
which  the  head  of  the  autosite  is  surmounted  by  another  head, 
placed  vertex  to  vertex.  This  is  evidently  a  stunted  symphyo- 
cephalus.  Epignathus  is  a  double  monster  in  which  an 
incomplete  fetus  is  rooted,  by  its  blood  vessels,  in  the  palate 
of  one  more  complete.  Heterodidymus  is  a  living  autosite  to 


DEFECTIVE    DEVELOPMENT   AND   GROWTH.  241 

which  is  affixed,  as  a  parasite,  a  small  doll-like  twin,  attached 
to  the  thorax.  Notomeles  and  pygomeles  monsters  are  para- 
sites which  have  a  single  extremity  attached  between  the 
shoulder  blades,  or  to  the  sacrum  of  the  autosite. 

All  the  monsters  heretofore  enumerated  are  classified  aa 
foetus  in  foetu  per  implantationem,  in  contradistinction  to 
foetus  in  foetu  per  inclusionem.  In  the  latter  the  parasite  not 
only  takes  root  in  the  autosite,  but  is  entirely  enclosed  by  the 
latter,  i.  e.,  they  have  one  skin  in  common.  The  most  import- 
ant members  of  this  class  are  found  in  the  inborn  tumors  of 
the  spinal  column  and  throat.  In  the  former  an  extensive 
tumor,  often  as  large  as  a  man's  head,  is  situated  in  front  of 
the  spinal  column,  completely  covered  by  the  skin.  Its  bulk 
is  made  up  chiefly  of  a  melanotic,  sarcomatous  tissue,  but  con- 
tains also  portions  of  foetal  bodies,  especially  limbs,  and  occa- 
sionally flat  bones  or  jaw-like  structures  with  teeth.  Again, 
a  tumor  is  found  arising  from  the  end  of  the  spinal  column  in 
the  region  of  the  sella  turcica,  to  which  it  is  attached  by  the 
pedicle.  Extending  from  the  throat,  it  emerges  in  shapeless 
masses  from  the  mouth.  The  bulk  of  this  tumor  is  also  made 
up  of  all  sorts  of  sarcomatous  tissue.  Occasionally  we  see, 
intermingled  with  individual  masses,  incomplete  arms  and 
legs,  or  a  face,  which  is  recognized  as  such  by  two  pigmentary 
spots  corresponding  to  eyes,  and  an  opening  for  the  mouth. 

2.    DEFECTS   OF   INTRA-UTERINE   DEVELOPMENT. 

{Defective  Formation^) 

The  manner  in  which  the  body  is  formed,  both  in  its  col- 
lective shape  and  in  its  individual  parts,  is  a  favorite  subject 
for  modern  research.  Any  one  with  an  imagination  at  all 
vivid  can  view  a  process  of  uninterrupted  development,  and 
watch  the  leaf-shaped  embryo  until,  after  manifold  trans- 
formations, it  assumes  the  form  of  a  definite  living  being. 
It  is  not  my  intention  to  depict  here,  even  in  a  hasty  manner, 
that  series  of  shifting  changes  which  succeed  each  other  until 
the  curving  edges  of  the  leaf  unite  and  form  an  entity.  The 
great  number  of  monsters  and  inborn  monstrosities  of  indi- 
vidual organs  testify  to  the  equally  large  number  of  disturb- 
ances to  which  the  typical  process  of  evolution  is  subject, 
disturbances  originating  in  a  defective  constitution  and  forma- 
tive activity  of  the  germ,  or  produced  by  disease  and  unfavor- 
able local  conditions. 


242  GENERAL   PATHOLOGY. 

To  defective  formative  activity  is  referable  first  of  all  the 
incomplete  closure  of  the  different  bodily  cavities — the  cleft 
formation,  in  the  broad  sense  of  the  word.  The  so-called 
diverticulum  of  Meckel,  of  the  small  intestines,  is  the  first 
intimation  of  delayed  closure  of  the  navel ;  this  is  followed  by 
congenital  umbilical  hernia  and  an  escape  of  all  or  the  greater 
part  of  the  intestines  from  the  abdominal  cavity.  Further 
down  we  have  defects  in  the  anterior  wall  of  the  bladder 
(exstrophy),  in  which  there  is  a  deficiency  in  the  anterior 
parietes  of  the  abdomen,  extending  up  to  the  umbilicus,  with 
an  equal  absence  of  the  pubic  symphysis.  Hiatus  sterni  is  a 
longitudinal  cleavage  of  the  sternum,  which  may  be  increased 
by  muscular  action,  but  is  entirely  covered  by  the  skin. 

Single  and  double  hare-lip  are  congenital  deformities  of  the 
face,  in  which  the  sides  of  the  lip  fail  to  unite.  Fistula  colli 
congenita  is  a  deformity  in  the  neighborhood  of  the  ear  and 
neck.  The  former  are  due  to  defective  union  between  the 
horizontal  plates  of  the  superior  maxillary,  the  inter-maxillary, 
and  the  palate  bones.  These  malformations  range  from  a 
slight  cleft  in  the  upper  lip — usually  on  the  left  side — up  to 
large  double-sided  fissures,  which  not  only  cleave  the  lips  up 
to  the  orbit,  but  also  the  hard  and  soft  palate.  Congenital 
fissures  of  the  neck,  extending  frequently  up  to  the  ear,  are 
the  result  of  a  defect  in  the  corresponding  foetal  parts. 

Normal  closure  is  particularly  apt  to  be  lacking  in  the 
cerebro-spinal  cavities.  The  defective  formation  here  is  re- 
ferable rather  to  a  premature  dropsical  condition  of  the  brain 
and  spinal  cord  (internal  hydrocephalus)  than  to  a  defective 
nisus  formativus.  Congenital  hydrocephalus  is  the  mildest 
appearance  of  the  former.  If  the  hydrocephalus  appear  at  a 
time  when  the  brain  and  spinal  marrow  are  still  composed  of 
vesicles,  the  vesicles  burst,  and  the  implantation  seats  of  the 
brain  and  spinal  cord  disappear.  Anencephalia  and  amylia 
are  the  results.  There  is  not  the  slightest  effort  made  towards 
the  formation  of  a  skull  or  spinal  column.  There  is  a  striking 
similarity  in  the  faces  and  bodies  of  all  anencephali  (frog's 
head).  The  absence  of  the  nervous  system  induces  a  cessation 
of  all  individual  development. 

If,  in  the  process  of  further  development,  the  hydrocephalic 
accumulation  of  water  localizes  itself  at  a  particular  spot, 
there  results  local  cleft  formation  of  the  skull  and  spinal 
marrow,  known  as  encephalocele  and  spina  bifida.  In  every 


DEFECTIVE    DEVELOPMENT   AND   GROWTH.  243 

instance  the  development  or  non-development  of  the  envelop- 
ing bones  and  skin  is  in  proportion  to  the  development  of  the 
brain. 

A  continuous  pressure  exerted  upon  the  foetus  in  utero 
from  without  can  only  be  recognized  as  a  factor  of  disturb- 
ance when  there  is  a  lack  of  liquor  amnii,  whose  special 
function  it  appears  to  be  to  counteract  the  effects  of  pressure. 
Geminus  papyraceus  is  the  most  palpable  illustration  of  such 
a  condition.  Here  we  find,  in  a  uterus  whose  interior  is  almost 
wholly  occupied  by  a  well-developed  twin,  a  second  one  which 
has  been  literally  forced  to  the  wall,  and  which  comes  into  the 
world  as  a  small,  compressed  corpse.  The  so-called  "  heartless 
monstrosities"  are  examples  of  stunted  twins.  In  them  not 
only  the  heart,  but  often  the  head  is  lacking  (Acephalus),  or 
the  head  and  the  trunk  (Acormus).  Sometimes,  indeed,  there 
is  nothing  more  than  a  shapeless  mass  of  tissue  covered  with 
skin  (Anidaeus). 

A  slight  pressure  on  the  foetus  causes  "  a  diminution  in 
size  "  of  certain  parts  of  the  body.  Hence  we  have  the  under- 
sized brain  and  skull  (Microcephalus),  and  an  arrested  develop- 
ment of  those  layers  and  plates  which  adjoin  each  other  in  the 
median  line  of  the  body,  causing  defects  of  smell  and  sight. 
Occasionally  the  middle  portions  of  the  skull  anteriorly  are 
absent,  and  also  the  upper  part  of  the  face.  In  the  latter, 
both  eyes  unite  in  a  single  monstrous  cyclopian  orb  (Cyclops). 
Here  likewise  belong  the  syrens,  a  variety  of  monsters  which 
have  the  lower  extremities  joined  together.  Congenital  dislo- 
cations and  club  foot  are  probably  both  due  to  impeded  normal 
evolution. 

The  last  group  of  intra-uterine  malformations,  and  one 
especially  interesting  to  physicians,  concerns  extremely  in- 
genious but  complicated  metamorphoses  by  which  are  formed 
(1)  the  central  rudiments  of  the  blood  vessels  leading  into 
the  heart  and  large  vessels,  (2)  the  indifferent  rudiments  of 
the  uro-genital  apparatus  which  subsequently  terminate  in 
the  permanent  male  or  female  genito-urinary  organs,  and  (3) 
the  separate  excretory  passages  for  the  intestines,  bladder  and 
genital  apparatus. 

If  the  primary  position  of  the  heart  be  toward  the  right, 
not  only  is  the  apex  of  the  heart  inclined  to  the  right, 
but  a  complete  change  of  the  asymmetrical  bodily  organs  is 
brought  about,  so  that  the  liver  and  spleen  lie  on  the  left  side, 


244  GENERAL    PATHOLOGY. 

the  aorta  is  on  the  right,  the  vena  cava  is  on  the  left  (situs 
viscerum  inversus).  Again,  the  so-called  isthmus  of  the  aorta, 
between  the  subclavia  and  the  ductus  arteriosus  Botalli, 
proves  to  be  a  somewhat  uncertain  provision,  as  it  is  occa- 
sionally defectively  developed,  and  the  blood  is  thus  forced  to 
traverse  the  collaterally-dilated  branches  of  the  internal 
mammary,  the  transversus  colli,  the  scapular  and  other  arteries 
of  the  trunk,  in  order  to  reach  the  branches  given  off  by  the 
descending  aorta.  In  cases  where  there  is  an  early  inflamma- 
tory stenosis  of  the  right  conus  arteriosus  and  pulmonary 
valves,  the  retarded  formation  of  the  intra-ventricular  and 
auricular  walls  is  of  a  very  salutary  effect.  The  blood,  which 
cannot  after  birth  reach  the  lung  in  the  ordinary  way,  flows 
through  the  patulous  foramen  ovale  in  the  interauricular  wall, 
and  through  the  permanent  gap  in  the  interventricular  wall, 
in  order  to  reach  the  left  heart  and  aorta,  and  thereby  eventu- 
ally the  lungs,  through  the  ductus  arteriosus  Botalli.  The 
history  of  cyanopathy  shows  this  to  be  but  a  scanty  compen- 
sation, yet  it  prolongs  life  for  a  time  at  least. 

The  most  ordinary  anomalies  of  the  genital  apparatus  are 
those  connected  with  the  ducts  of  Miiller  and  the  uterus. 
Such  are  the  uterus  bicoruis,  in  which  the  Miillerian  ducts 
begin  at  the  orificium  intemum  to  unite  into  a  simple  canal ; 
the  uterus  bipartivus,  in  which,  although  the  ducts  unite  and 
form  a  single  body,  the  cavity  is  divided  by  a  partition- wall ; 
the  uterus  unicornis  where  only  one  of  the  Miillerian  ducts 
reach  maturity ;  lastly,  the  uterus  defectivus,  where  both  ducts 
fail  to  develop. 

Hermaphroditismus  is  another  example  of  defective,  one- 
sided development  of  the  genital  organs.  It  is,  generally 
speaking,  more  apparent  in  the  external  genital  organs  than 
in  the  internal  ones,  for  we  find,  upon  subjecting  the  genital 
glands  to  microscopic  examination,  that  we  have  really  a  male 
before  us.  The  first  indication  of  hermaphrodeity  is  afforded 
by  a  small  slit  in  the  urethra,  pointing  backwards.  The  orifice 
of  the  urethra  is  then  transferred  to  the  base  of  the  penis, 
the  latter  assumes  the  shape  of  a  clitoris,  and  its  foreskin  is 
reflected  in  folds  on  both  sides.  As  the  penis  becomes  more 
and  more  like  the  clitoris,  these  folds  resemble  the  labia 
minora.  Advancing  inward,  we  find  that  the  utriculus  pros- 
taticus  has  developed  into  a  structure  of  considerable  length, 
extending  by  its  fundus  beyond  the  stunted  prostate ;  we  see 


DEFECTIVE    DEVELOPMENT   AND   GROWTH.  245 

the  ligamenta  rotunda  and  lata,  in  which  latter  the  genital 
glands  are  enclosed.  We  observe,  instead  of  a  single  scrotum, 
two  folds  of  skin  reflected  to  the  right  and  left.  They  may 
be  compared  to  the  labia  majora.  These  folds  are,  as  a  rule, 
empty,  but  there  have  been  instances  where  one  testicle  has 
descended.  Hermaphrodeity  is  generally  better  developed  on 
one  side  than  on  the  other.  A  perfectly  distinct  hermaphro- 
dite, in  which  both  ovaries  and  testicles  are  present,  has  been 
observed  but  once,  at  least,  in  man.  In  this  instance,  the  ex- 
ternal organs  of  generation  resembled  those  of  a  man. 

The  separate  orifices  pertaining  to  the  rectum,  the  urethra, 
and  in  the  female  to  the  vagina,  are  formed,  as  is  well  known, 
about  the  fourth  week  of  foetal  existence,  by  a  seasonable 
division  of  the  "cloaca"  belonging  to  the  orifices.  Should, 
however,  the  respective  partition  walls  fail,  in  women,  to  move 
down  into  their  place,  the  "  cloaca "  persists.  This  defect  is 
most  serious  when  the  anterior  wall  of  the  bladder  is  absent. 

Simple  atresia  of  the  anus  is  far  more  common.  In  it 
the  lower  end  of  the  gut  does  not  quite  extend  through  the 
buttocks. 

3.    DEFECTIVE   EXTRA-UTERINE    DEVELOPMENT. 

The  subject  which  we  have  now  to  consider  is  a  difficult 
one.  It  concerns  the  inherited  weaknesses  of  certain  organs 
or  systems  of  the  body,  in  which  there  is  at  birth  no  tangible 
abnormality,  but  which  develop  in  after  life  pathological  dis- 
turbances either  of  function  or  form. 

All  the  organs  of  the  body,  as  we  know,  do  not  increase 
equally  in  size  during  the  period  of  extra-uterine  develop- 
ment. In  fact,  the  irregularities  observed  in  intra-uterine 
development  are  continued  in  extra-uterine  life.  The  growth 
of  the  organs  may  be  compared  to  a  race  in  which  first  one, 
then  another  of  the  organs  takes  the  lead.  The  best  developed 
at  birth  are  the  brain  and  liver.  After  the  air  has  penetrated 
the  lungs,  and  the  process  of  digestion  has  been  established, 
the  lungs  and  intestines  take  the  lead.  Soon  the  child  learns 
to  stand  and  walk,  and  make  a  general  use  of  the  musculo- 
motor  apparatus.  Accordingly,  we  observe  between  the  end 
of  the  first  and  the  end  of  the  fifth  year  a  powerful  growth 
of  the  bones,  muscles,  and  corresponding  nerves.  A  similar 
stage  is  that  between  the  ages  of  fifteen  and  twenty,  during 
wh?ch  the  body  attains  full  development.  At  these  periods 


246  GENERAL   PATHOLOGY. 

the  blood  and  blood-vessels — particularly  the  heart — are  far 
behind  in  the  race.  When  we  consider  that  the  development 
of  the  genital  apparatus  at  puberty,  and  the  psychical  excita- 
tions resulting  therefrom,  require  an  unusual  supply  of  blood, 
we  can  readily  understand  why  this  period  of  growth  should 
be  regarded  as  particularly  critical. 

At  this  time  of  disproportion  in  the  rate  of  growth  of  organs, 
we  often  have  the  first  indication  of  inherited  weaknesses. 
Inherited  nervous  troubles  appear  in  the  recurrence  of  neu- 
roses descending  from  parents  or  grandparents,  though  with 
the  limitation  that  most  of  them  appear  vicariously,  one  for 
another,  or  may  be  replaced  by  groups  of  symptoms  which  are 
less  sharply  defined,  and  even  by  tangible  anatomical  changes 
in  the  brain  and  spinal  cord.  Under  this  head  stand  epilepsy, 
psychosis,  hysteria,  idiocy,  and  chorea  major,  with  retarded  de- 
velopment of  the  brain,  and  even  hydrocephalus.  To  be  also 
noted  is  insufficiency  of  the  sphincter  muscles,  causing  lagoph- 
thalmia,  incontinence  of  urine,  spermatorrhoea,  and  that  "foolish 
dropping  down  of  the  lower  lip,"  mentioned  by  Shakespeare  in 
one  of  his  dramas ;  also,  defects  of  accommodation,  color  blind- 
ness, etc.  In  short,  be  the  nervous  system  affected  where  it 
may,  the  great  capacity  of  this  tissue  is  evident  in  its  power  to 
record  impressions  and  transmit  them  to  later  generations. 

Some  of  the  tumors  also  arise  at  this  period  of  rapid  bodily 
growth.  I  have  already  (p.  41)  indicated  my  views  regarding 
the  participation,  or  rather  non-participation,  of  the  nervous 
system  in  the  origin  of  tumors.  It  must  be  borne  in  mind 
that  the  periods  of  rapid  growth  in  organs  are  equally  the 
periods  of  greatest  irritability.  This  is  seen  most  distinctly  in 
certain  inflammatory  and  sub-inflammatory  conditions  of  the 
osseous  system.  It  is  true  that  we  are  at  present  unable  to 
assign  a  definite  cause  for  rachitis  (rickets),  that,  we  might 
almost  say,  inflammatory  disturbance  in  the  growth  of  bones. 
But,  be  the  cause  an  hereditary  transmission  of  disease 
(syphilis),  or  an  individual  disturbance  of  tissue  change, 
every  one  must,  I  think,  admit  that  it  must  be  a  continuous 
one,  since  it  affects  the  system  at  the  two  periods  of  rapid 
growth  already  mentioned,  viz.,  in  the  first  year  of  extra- 
uterine  life,  and  at  the  time  of  puberty.  (Early  and  late 
rickets.)  We  also  know  very  little  in  regard  to  the  etiology 
of  cretinism,  whose  results  are  opposed  to  those  of  rickets,  in 
that  it  hinders  the  transformation  of  cartilage  into  bone,  and 


DISEASES   DUE   TO   OVER- EXERTION.  247 

arrests  the  development  of  the  skull  and  skeleton.  It  is  well 
known  that  inherited  tuberculosis  chiefly  attacks  the  growing 
bones,  and  that  more  than  one-half  of  all  cases  of  caries 
fungosa  (tuberculosis  of  bones)  are  restricted  to  youth. 

The  very  anatomical  changes  which  accompany  the  growth 
of  bones  develop  insensibly  on  the  one  hand  into  inflammation, 
on  the  other,  into  formation  of  tumors.  Examples  of  this  are  : 
periostitis,  ostitis  ossificans,  rarefying  myelitis,  also  the  numer- 
ous ecchondroses,  exostoses,  periostoses,  and  hyperostoses.  To 
be  brief,  the  temporary  weakness  in  the  continuity  of  the 
organs,  which  is  caused  by  the  powerful  growth  of  the  osseoua 
system,  not  only  makes  them  susceptible  to  external  irritation, 
but,  associating  itself  with  local  weakness  already  existing 
in  the  individual  plan  of  development,  conducts  in  the  former 
to  inflammatory,  in  the  latter  to  onkological  excesses  of  growth. 
I  have  mentioned  the  osseous  system  in  particular  merely  to 
illustrate  the  most  important  theories  regarding  diseases  of 
growth,  and  must  leave  it  to  the  reader  to  seek  analogous 
instances  in  other  organs. 

I  have  alluded  briefly  to  an  important  group  of  local 
excesses  in  growth,  viz.,  tumors.  Their  origin  was  discussed 
in  detail  in  the  General  Part ;  I  shall,  accordingly,  limit  my- 
self to  the  statement  that  in  many  tumors  we  can  assign  no 
better  cause  for  their  origin  than  a  possible  inherited  weakness 
in  the  relationship  between  a  local  group  of  cells  and  theorganic 
unit  of  the  body — in  the  first  instance,  probably  the  nervous 
system — to  which  disturbance  the  remainder  of  the  recognized 
predisposing  causes  may  lead.  Inflammatory  conditions, 
scars,  etc.,  are  to  be  included  among  these ;  also  the  senile 
involution  of  the  whole  organism,  which  favors  the  local 
emancipation  of  such  tissues  as  are  already  of  a  more  inde- 
pendent growth,  especially  the  epithelial,  and  thus,  either  alone 
or  more  frequently  in  connection  with  chronic  inflammatory 
irritants,  gives  rise  to  cancerous  growths.  See  also  page  251. 

IV.  DISEASES  DUE  TO  OVER-EXERTION. 

Every  active  organ  becomes,  in  the  course  of  time,  fatigued, 
and  requires  rest  to  fit  it  for  renewed  activity.  If  this  rest  is 
not  afforded,  if  the  organ  is  forced  by  continuous,  even  though 
physiological  irritation  to  "over-exertion,"  it  will,  although 
in  a  measure  responding  to  the  summons,  do  so  at  the  risk  of  in- 
curring serious  harm,  not  only  to  itself,  but  to  the  entire  body. 


248  GENERAL    PATHOLOGY. 

We  mentioned  (pp.  17  and  18),  the  means  at  the  command 
of  the  organism  for  supporting  and  preserving  its  organs  when 
extra  demands  for  work  are  made  upon  them.  The  hypene- 
mia  produced  in  such  cases  not  only  furnishes  a  more  abundant 
supply  of  nutritive  material  by  which  to  replace  that  con- 
sumed, but  it  affords  more  oxygen  to  aid  the  work,  and  a 
working  organ  is  a  consuming  organ.  Here,  as  elsewhere, 
the  destruction  progresses  more  rapidly  than  the  restoration. 
Accordingly,  the  organ  must,  from  time  to  time,  have  rest,  in 
order  that  nutrition  may  keep  pace  with  consumption.  Now, 
if  no  rest  is  afforded  the  organ,  and  the  nervous  system  con- 
tinues its  demands  for  extra  work  and  establishes  an  active 
hypersemia,  it  is  plain  that  a  double  danger  must  result. 
First,  the  protoplasm  of  the  active  cells  may  be  too  much 
drawn  upon,  the  organ  become  worn  out,  even  partially 
atrophied,  and  so  exhausted  as  to  require  a  prolonged  period 
of  rest  before  it  can  regain  its  normal  condition.  Second,  the 
excessively  protracted  active  hypersemia  harbors  in  itself  a 
danger.  The  longer  the  duration  of  an  arterial  hypersemia, 
the  slower  and  more  incomplete  its  disappearance.  The  cause 
of  this  appears  to  be  in  a  certain  relaxation  in  the  walls  of 
veins  especially,  after  they  have  remained  for  some  time  in  a 
condition  of  passive  dilatation.  If  the  return  to  normal  is 
indefinitely  postponed,  the  active  hypersemia  becomes  an 
independent  condition  of  disease,  forming  the  basis  for  further 
changes  of  an  inflammatory  nature. 

Over-work,  and  the  diseases  resulting  therefrom,  occur 
chiefly  in  the  organs  of  sensation  and  motion.  It  is  here  that 
the  reckless  use  of  the  enormous  stock  of  elasticity  which  is 
lodged  in  the  central  nervous  system  produces  a  renewed  and 
sufficient  excitation,  even  in  the  exhausted  and  therefore  less 
excitable  terminal  apparatus.  It  is  true  that  over-use  also 
occurs  in  organs  presiding  over  nutrition  and  generation, 
but  careful  consideration  shows  that  it  is  then  an  unreasonable 
use  of  "  free  will,"  which  produces  in  the  above-named  systems 
an  excessive  and  harmful  activity,  by  calling  into  play  pow- 
erful and  unnecessary  physiological  irritants. 

Although  it  must  be  admitted  that  over-work  constitutes  an 
independent  cause  of  disease,  still  its  effects  are  rarely  seen  in  dis- 
tinct and  well-defined  pictures  of  disease ;  on  the  contrary,  they 
frequently  present  to  the  physician  kaleidoscopic  images,  in 
which  over-exertion  constantly  recurs  as  the  prominent  motive. 


DISEASES    DUE   TO   OVER-EXERTION.  249 

The  attacks  of  the  great  majority  of  insane  people  are  due 
to  a  functional  irritation  of  the  cortical  substance  of  the 
cerebrum.  Although  a  congenital,  inherited,  or  acquired 
weakness  and  incapacity  for  resistance  may  be  found  in  the 
diseased  brain,  yet  the  status  presens  is  an  excessive  activity 
of  the  cortical  cells,  which  has  produced  an  equally  excessive 
and  proportionally  "  lasting  hypersemia."  This  tenacity  of 
the  hypersemia  develops  a  drculus  mtiosus.  The  hypertemic 
cortical  substance  of  the  brain  is  in  itself  active.  The  hyper- 
semia is  closely  united  to  functional  excess,  and  a  patient  may 
consider  himself  fortunate  if  his  skillful  physician  is  able,  by 
the  most  powerful  remedies,  to  break  up  the  circulus  vitiosus. 

The  over-exercise  of  the  sexual  organs,  especially  in  sexual 
intercourse,  and  similar  sexual  excitations,  leads  more  fre- 
quently than  is  supposed  to  true  diseases  of  this  kind 
There  are  many  diseases  which  are  observed  only,  or  at  least 
preponderatingly,  in  men.  Nature  has  implanted  in  man, 
side  by  side  with  a  limited  degree  of  sexual  capacity,  that 
boundless  passion  by  which  the  race  is  propagated.  It  thus 
happens  that  men  demand  too  much  of  their  organs  of  gen- 
eration, and  must,  of  course,  suffer  the  consequences.  I  am 
a  priori  inclined  to  attribute  all  diseases  of  the  nervous  system 
which  are  peculiar  to  men  to  sexual  excesses,  knowing  full 
well  that  it  will  never  be  possible  for  me  or  any  other  physician 
to  properly  estimate  the  significance  of  this  etiological  factor. 

Short-sightedness  is  sometimes  regarded  as  a  result  of  over- 
use. In  the  majority  of  cases,  it  is  hereditary,  although  many 
near-sighted  persons  attribute  the  defect  to  over-exerting  their 
eyes  in  reading  small  print,  and  working  with  insufficient  light. 
Bad  school  desks,  i.  e.,  with  the  seat  at  some  distance  from  the 
desk,  tables  which  are  too  high  or  too  low,  compelling  children 
to  focus  from  a  short  distance,  are  especially  to  blame.  Long- 
continued  strain  upon  the  apparatus  of  accommodation  is  of 
itself  not  sufficient  to  lengthen  the  visual  axes,  but  this  is  done 
when  it  is  combined  with  the  tension  which  accompanies  strong 
convergence  of  the  visual  axes,  in  which  the  bulb  of  the  eye  is 
lengthened  and  the  sclerotic  extended  by  the  pressure  of  the 
muscles  of  the  eyeball.  Moreover,  by  the  bending  forward  of 
the  head  congestion  ensues,  which  favors  softening  of  the  latter 
membrane.  As  all  of  these  things  occur  in  certain  degrees, 
even  when  the  eyes  are  used  in  moderation,  myopia  is  a  good 
example  of  the  "  using  up  "  of  an  organ  by  over-use. 


250  GENERAL    PATHOLOGY. 

V.  DISEASES  OF  INVOLUTION. 

The  ordinary  course  of  nature  provides  for  all  creatures  an 
easy  death  by  a  gradual  retrogressive  growth  (involutio)  of 
all  their  organs.  The  full  physical  development  is  reached  in 
the  thirtieth  year,  and  involution  begins  between  the  fiftieth 
and  sixtieth.  The  formation  of  blood  abates,  the  monthly 
discharge  of  the  female  ceases,  and  nature  becomes  more 
economical  with  its  blood.  It  is  no  longer  able  to  assist 
several  organs  simultaneously  with  an  active  hypersemia ;  on 
the  contrary,  when  the  stomach  demands  additional  blood, 
the  brain  must  dispense  with  it,  and  vice  versa.  The  continued 
determination  of  large  quantities  of  blood,  as  required  in 
sexual  intercourse,  becomes  rarer  and  more  imperfect.  As 
the  blood  diminishes  in  quantity  there  is  also  a  diminution  in 
the  directly  dependent  juices  of  the  tissues,  called  turgor 
vitalis.  The  skin  grows  flabby  and  shrivelled,  the  iron 
strength  of  the  powerfully  contracted  muscle  relaxes,  and 
even  the  cushion  of  fat,  whose  augmented  size  for  a  time  con- 
ceals the  increasing  atrophy  of  the  parts,  is  itself  soft  and 
flabby,  and  but  a  pitiful  caricature  of  the  classically  full  and 
rounded  outlines  of  youth. 

All  the  organs  and  tissues  become  successively  involved  in 
this  general  deterioration  of  nutrition.  Not  all  organs,  how- 
ever, claim  an  equal  amount  of  nutriment  from  the  blood ; 
there  are  some  which  require  a  constant  and  very  abundant 
blood  supply,  while  others  are  able  to  dispense  almost  alto- 
gether with  the  blood  supply.  The  former — the  heart  and 
liver — begin  at  once  to  give  evidence  of  diminished  nutrition 
by  a  certain  atrophy  of  their  cells,  while  all  the  connective 
tissue  parts,  membranes,  tendons,  ligaments,  sheaths,  etc., 
remain  unchanged  in  bulk.  All  the  other  bodily  organs  are 
ranged  between  these  two  extremes.  Next  in  order  to  the 
liver  are  the  lungs,  then  the  osseous  system,  the  muscles,  the 
nervous  system,  and  finally,  the  epithelial  structures. 

It  is  not  my  intention  to  intimate  by  the  foregoing  observa- 
tions that  all  senility  is  referable  to  defective  blood  formation. 
I  desire,  on  the  contrary,  to  emphasize  the  fact  that  every 
organ  of  the  body  possesses  a  certain  individual  durability, 
which  is  determined  by  the  development  of  the  person  in 
question  and  the  factors  contributing  thereto  (p.  41) — a  dura- 
bility, to  my  thinking,  to  which  the  organ  is  as  it  were 
adjusted.  Individual  differences  of  this  sort  are  most  marked 


DISEASES   OF   INVOLUTION.  251 

in  the  blood  vessels,  higher  organs  of  sense,  and  genital  glands, 
in  which  the  appearance  of  certain  forms  of  premature  invo- 
lution cannot  be  explained  by  immoderate  physiological  use. 
For  natural  exercise,  non-exercise  and  immoderate  exercise  of 
an  organ  during  a  person's  lifetime,  all  exert  a  determining  in- 
fluence upon  the  vitality  of  the  organ.  This  influence  is  mani- 
fested primarily  upon  its  growth  and  nutrition,  as  discussed 
at  length  on  pp.  16,  17  ;  the  surplus  gained  by  a  moderate 
amount  of  active  hypertrophy  may  be  properly  regarded  as 
so  much  capital  for  the  use  of  the  organ  in  its  advancing 
years.  The  lungs,  muscles,  and  also  the  larynx  are  especially 
capable  of  being  permanently  strengthened  by  methodical 
exercise.  Non-exercise,  on  the  other  hand,  no  less  than  ex- 
cessive employment,  leads  to  premature  incapacity,  and,  at 
last,  to  atrophy  of  the  organ  concerned.  Such  occurrences 
are  not  surprising  at  the  present  time,  when  a  division  of  labor 
is  becoming  more  and  more  universal,  and  when  many  per- 
sons are  obliged  during  the  entire  day  to  repeat  again  and 
again  at  stated  intervals  the  same  automatical  labor. 

It  is  scarcely  necessary  to  state  that  the  pathological  changes 
which  are  undergone  by  an  organ  also  greatly  influence  its 
vitality  and  usefulness.  Such,  pre-eminently,  are  chronic 
inflammatory  conditions,  especially  those  due  to  intoxicating 
liquors. 

The  above  is  a  sufficiently  complete  summary  of  the  causes 
of  normal  or  premature  senectus  (senility).  Whether  such 
senility  is  or  is  not  "pathological"  in  character,  remains  a 
debatable  point.  One  peculiar  feature  of  tissues  as  they  grow 
old,  and  one  which  must  be  construed,  not  only  as  a  cause, 
but  also  as  an  effective  disease  is  "  senile  tissue-proliferation." 
The  epithelium  and  osseous  tissues  as  well  as  (with  restric- 
tions) the  tissues  of  the  inner  coat  of  arteries,  are  subjected  to 
senile  proliferation.  The  chief  diseases  of  extreme  old  age  in 
this  department  are  many  varieties  of  epithelial  carcinoma, 
arthritis  deformans,  chronic  endarteritis. 

The  fact  that  these  tissues  should,  upon  the  first  signal 
of  general  involution,  at  once  commence  to  increase  by  cell 
division,  and  fall  a  prey  to  an  unlimited  degenerative  growth, 
is  one  of  the  strangest  paradoxes  in  pathology,  and  one  whose 
explanation  can  only  be  vaguely  conjectured. 

A  very  ingenious  theory  is  that  offered  by  Thiersch,  who 
attributes  to  the  epithelial  structure  a  sort  of  perverted  growth 


252  GENERAL    PATHOLOGY. 

due  to  diminished  resistance,  which  is  brought  about  by  the 
diminished  turgor  vitalis  in  the  blood  vessels  and  connective 
tissue.  As  the  epithelium  proliferates  normally  by  division 
on  the  side  nearest  the  connective  tissue,  there  would  be 
nothing  astonishing  in  a  continued  aggregation  and  deposition 
on  this  side,  in  other  words,  an  advance  of  the  epithelial 
limits  towards  the  interior;  the  only  difference  being  that, 
normally,  the  point  offering  the  least  resistance  to  this 
demand  for  space  is  found  on  the  exterior,  instead  of  on  the 
interior.  If  this  arrangement  were,  as  Thiersch  presumes, 
reversed  in  advancing  age,  there  would  be  danger  of  the 
epithelium  proliferating  into  the  connective  tissue,  i.  e.,  pro- 
ducing carcinomatous  degeneration. 

Two  other  etiological  considerations  are  still  deserving  of 
attention,  as  throwing  light  upon  the  local  circumscribed 
appearance  of  cancer.  First,  the  usually  distinct  sub- 
inflammatory  condition  of  the  diseased  territory,  which  by  an 
abundant  cell -in  filtration  produces  a  softening  and  breaking 
down  of  the  firm  connective  tissue  fibres,  and  a  subsequent 
diminution  in  the  power  of  resistance  which  the  territory  is 
able  to  oppose  to  the  incursions  of  the  proliferating  epithelium. 
Second,  the  relatively  great  independence  which  distinguishes 
the  growth  of  the  epithelium.  The  epithelium  never  yields 
entirely  to  the  universal  cessation  of  growth,  which  sets  in,  in 
all  non-epithelial  organs,  between  the  ages  of  twenty  and  thirty. 
The  losses  sustained  by  the  shedding  of  the  older  cells  are 
continually  repaired  by  the  formation  of  young  cells.  The 
measure  of  this  growth  is  probably  subject  to  the  control  of 
the  nervous  system.  We  have  already  (p.  41)  accorded  to 
the  nervous  system  an  important  influence  in  the  supervision 
of  the  normal  limits  of  growth,  and  the  latest  discoveries  re- 
garding the  "  nerve  terminations  in  the  epithelium  "  authorize 
us  to  assume  a  similar  supervision  in  the  case  of  epithelial 
growth.  The  measure  of  this  authority  is,  however,  un- 
doubtedly of  an  extremely  vacillating  nature.  The  nervous 
relation  may  be  fundamentally  weak,  and  even  at  certain 
points  hampered  with  hereditary  defects.  It  is  not  improb- 
able that  by  the  intervention  of  still  other  etiological  features — 
especially  an  inflammatory  loosening  of  the  epithelial  con- 
nective tissue  boundaries — this  restraining  influence  of  the 
nervous  system  might  be  weakened  and  suspended.  I  must 
acknowledge  that  these  speculations  have  something  visionary 


DISEASES   OF   INVOLUTION.  253 

about  them,  yet  I  know  not  how  else  to  consider  these  matters 
which  daily  intrude  themselves  upon  our  notice,  and  I  cannot 
overcome  the  desire  to  discuss  them  in  this  general  manner. 

The  skin  is  principally  subject  to  senile  carcinoma ;  after 
that,  the  stomach,  intestines,  uterus,  prostate  gland,  etc. 

An  exhaustive  survey  of  the  malum  senile  articulorwn 
proves  it  to  be  a  tendency  towards  peripheral  hyperplasia 
which  involves  the  entire  osseous  system  of  the  body.  Carti- 
laginous excrescences  are  found,  not  merely  on  the  edges  of 
the  articular  cartilage,  where  they  give  rise  to  the  character- 
istic disfigurations  of  arthritis  deformans,  but  also  under  the 
perichondrium  of  the  costal  cartilages,  and  even  of  the  tracheal 
annular  cartilage.  The  changes  in  question  are  most  frequent 
in  the  costal  cartilages,  and  they  offer  convenient  subjects  for 
microscopical  investigation.  I  have  chosen  a  sufficiently  thin 
section  of  a  good-sized  costal  cartilage  with  which  to  illustrate 
the  nature  of  the  histological  changes. 

In  surveying  the  entire  section  with  a  low  magnifying 
power,  we  perceive  it  to  be  divided  by  certain  pretty 
broad  lines  into  six  or  seven  territories.  A  large  round 
central  area  is  bounded  by  several  small  oval  areas.  In 
the  asbestos-like  border  lines  of  division  we  find  the  matrix 
of  the  cartilage  split  into  fibres  and  undergoing  a  process 
of  softening  and  liquefaction,  while  the  matrix  in  the  areas 
is  of  a  homogeneous,  strongly-transparent  constituency. 
Certain  portions  of  the  cartilaginous  tissue  are  suffering 
from  distributed  nutrition,  which  we  regard  as  a  primary 
factor  of  the  change,  and  one  directly  due  to  senility.  With 
this  disturbance  of  nutritioti  there  is  associated  in  the  most 
surprising  manner  a  second  circumstance ;  the  cartilagi- 
nous cells  are  without  exception  in  the  act  of  proliferating 
by  division.  As  a  result,  we  see  in  the  direction  of  the  peri- 
chondrium flattened  and  even  conical  protrusions  consisting 
wholly  of  cellular,  almost  embryonic  cartilaginous  tissue,  and 
furnishing  the  real  cause  of  the  striking  external  deformity 
of  the  cartilage.  It  is  still  noticeable  that  the  central  car- 
tilage cells,  especially  those  within  the  domain  of  the  softened 
cartilage,  have  also  proliferated  by  division.  A  single  cell 
has  become  an  immense  round  nest  of  cells ;  from  10-20 
daughter-cells  are  still  retained  within  the  capsule  of  the 
mother-cell,  affording  thus  a  striking  demonstration  of  the 
productivity  of  a  single,  and  even  worn-out  cartilage  cell. 


254  GENERAL    PATHOLOGY. 

How,  we  ask,  does  the  cell  acquire  such  power?  In  the 
malum  senile  articulorum,  where  exactly  the  same  histological 
motive  is  found,  an  inflammatory  irritation  has  been  sur- 
mised, as  a  solution  for  the  difficulty.  Hence  the  name, 
arthritis  deformans.  In  my  opinion,  we  should  attribute  this 
senile  tissue  proliferation  to  a  removal  of  the  nervous  control 
over  the  assimilation  of  the  cells.  We  may  conceive  how, 
with  the  suspension  of  the  nutritive  relations  existing  between 
the  cartilage  and  blood,  there  should  be  a  decline  in  the  form- 
ative limitations  imposed  by  the  nervous  system,  and,  in  con- 
sequence, one  last  rise  in  assimilation,  that  elementary  prin- 
ciple of  cell-life.  The  fact  that  no  cartilage  nerves  have  as 
yet  been  discovered,  is  not,  I  think,  sufficient  ground  for 
denying  the  nervous  susceptibility  of  the  cartilage  tissue. 
The  fact  also  that  cases  of  arthritis  deformans  have  been 
cured  by  the  use  of  the  constant  current  is  certainly  not  un- 
favorable to  my  view. 

One  of  the  most  difficult  points  we  have  to  settle  is  the 
relation  which  arthritis  deformans  bears  to  atherorna  of  the 
arteries.  There  is  no  doubt  that  we  have  here  a  genuine, 
though  it  may  be  weak  and  gradual,  inflammation.  Koster 
has  established  a  hypersemia  of  the  vasa  vasorum,  and  a 
cellular  infiltration.of  the  surrounding  parts,  corresponding  to 
the  sclerotic  plates  of  the  intima.  I  have  subjected  these  ob- 
servations to  the  most  careful  scrutiny,  and  have  been  able  to 
verify  the  greater  part  of  them.  But  what  is  the  cause  of 
this  chronic  inflammation,  and  why  is  it  that  it  is  found — aside 
from  the  syphilitic  endarteritis  of  the  cerebral  arteries — only 
in  old  and  middle  aged  persons  ?  There  must,  of  necessity, 
be  some  connecting  link  in  the  etiology  of  this  disease  with 
the  natural  or  pathologically-induced  wasting  of  the  arterial 
system,  and  this,  if  I  mistake  not,  is  found  in  the  mechanical 
expansion  of  the  blood  vessels.  The  artery  is  built  and 
arranged  for  certain  moderate  degrees  of  dilatation.  It  like- 
wise accommodates  itself  to  occasional  greater  demands,  after 
which  it  returns,  to  all  appearances,  to  normal.  But  is  it  not 
possible  that  prolonged  or  violent  attacks  of  fever,  that 
increased  activity  of  the  heart  resulting  from  alcoholic  ex- 
cesses, from  violent  emotion,  muscular  exertion,  etc.,  should, 
after  frequent  repetitions  and  even  temporary  over-dilatation 
of  the  blood  vessels,  produce,  finally,  a  permanent  cumulative 
effect  ?  And  in  what  would  this  effect  consist  ?  First  of  all, 


CONCLUSION.  255 

assuredly,  in  a  general  dilatation  of  the  arterial  system,  such 
as  is  found  in  all  old  persons ;  after  that  in  a  strong  mechanical 
irritation  of  those  portions  of  the  vascular  system  which  are 
attached  in  such  a  manner  to  neighboring  parts  as  to  prevent 
them  from  dilating  when  an  excessive  dilatation  is  demanded. 
Such  points  are,  principally,  the  origin  of  the  various  arteries 
arising  from  the  aorta,  viz.,  intercostal,  bronchial,  mesenteric 
and  renal  arteries,  and,  in  especial,  the  large  vessels  arising 
from  the  arch  of  the  aorta.  In  addition,  we  have  the  prepon- 
derating expansion  of  those  points  where  there  is  most  friction 
from  the  increased  blood  current,  in  the  curves  and  ramifica- 
tions of  a  blood  vessel.  ^The  immediate  effect  of  mechanical 
irritation  of  all  these  points  is  a  permanent  hypersemia  of  the 
vasa  vasorum ;  the  secondary  result  is  a  hyperplasia  of  the 
intima.  The  entire  disease  bears  a  general  resemblance  to 
those  diseases  which  characterize  old  age. 

CONCLUSION. 

In  the  foregoing  sketch  I  have  endeavored  to  classify  the 
Natural  Species  of  Diseases,  according  to  their  principal  and 
sub-divisions.  This  might  be  construed  as  an  attempt  on  my 
part  to  add  another  to  the  long  list  of  pathological  systems  of 
disease  which  are  recorded  in  the  history  of  our  science. 
Nothing,  however,  can  be  further  from  my  purpose  than  to 
treat,  as  is  the  manner  of  those  systems,  each  particular  case 
of  disease  as  a  unit,  and  to  "  systematize  "  the  immense  num- 
ber and  variety  of  individual  cases.  In  our  special  pathology 
most  of  these  cases  of  disease  unite  in  themselves  several  of  the 
natural  disease  units,  which  proceed  from  the  unity  of  a 
definite  cause  of  disease  and  the  uniformity  of  its  operations 
upon  the  organism.  I  have  brought  these  natural  disease 
units,  varieties,  or  species,  into  a  new  relation,  which  I  call 
special  pathology  in  the  strictest  sense  of  the  word,  and  which 
I  regard  as  the  true  province  of  scientific  medicine. 

For  twenty  years  we  have  been  watching  the  birth  and 
development  of  this  new  pathology.  I  have  merely  attempted 
to  make  it  somewhat  more  intelligible,  and  while  guarding 
on  the  one  hand  against  the  inroads  of  specialistic  and 
casuistic  pathology,  to  emancipate  it  on  the  other  from  the 
enveloping  forms  of  general  pathology. 


INDEX. 


ABSCESS,  defined  ............................................................  ^27 

-  metastatic  .................................................................     72 

Actinomyces  .......................................................................  224 

Albuminuria  .......................................................................   140 

Anaemias,  essential  .......  ."  .......................................................  128 

Anaemia,  pernicious  ..............................................................  129 

-  pseudo-leucaemic  .......................................................  129 

-  splenic  .....................................................................  129 

Anaesthesia  .........................................................................  159 

Analgesia  ...........................................................................  160 

Angina  pectoris  ...................................................................  180 

-  tonsillaris  —  quinsy  .....................................................     35 

Angioma  .............................................................  .............     51 

Angio-neuroses  ....................................................................  179 

Animal  disturbances  ............................................................  159 

Arthropoda  ........................................................................  206 

Asthma  ..............................................................................  137 

Ataxia  ..............................................................................  173 

Atrophy  of  fatigue  ...............................................................     18 

-  of  inaction  ................................................................     18 

-  simple  .....................................................................     95 


disease  .........................................................  180 

Blood-  corpuscle  formation,  disturbances  in  ..............................  127 

Blood-formation,  disturbances  in  ............................................  121 

Blood-plates  of  Bizzozero  ......................................................     64 

Blood-purification,  disturbances  in  .........................................  133 

CACHEXIA  ........................  .  ................  ...........................    82 

Calcification  ...........................  .  ...........................................  100 

Carcinoma  .........................................................................     49 

Catalepsy  .............................................  .............................  167 

Catarrhs,  desquamative,  blennorrhoea,  seborrhcea  ................   33,  201 

Cestodes  .............................................................................  211 

257 


258  INDEX. 

PAOI 

Chill 7H 

Chlorosis 128 

Cholsemia 133,  148 

Chondroma 50 

Chorea 167 

Cicatrization 29 

Circulation,  collateral 102 

derangements  of. 101 

general,  derangements  of. 112 

Cleft  fungi 217 

Cloudy  swelling 31 

Coagulation-necrosis 31 

Coma...., 85 

Convulsions 161 

reHex 163 

Cyanosis 118 

Cysts,  dermoid 54 

retention 50 

softening 96 

DEATH  from  heart  failure 114 

signs  of. 114 

Decubitus  paralyticus 183 

Degeneration,  amyloid 83 

cheesy 227 

colloid 99 

fatty 94 

mucoid 98 

Delirium 85 

Delusions 178 

Development  and  growth,  defective 236 

Development,  extrauterine,  defective 245 

intrauterine  defective 241 

Diabetes  insipidus 139 

mellitus 143 

Diabrosis 109 

Diarrhoea 125 

Diapedesis 107 

Diathesis,  scrofulous 229 

uric  acid ..  145 


INDEX.  259 

_..  ,  PAGE 

Dieresis 108 

Disease,  Addison's 133 

definition  of. 9 

division  of. 186 

due  to  overwork 247 

local  outbreak  of. , 13 

of  involution 250 

paralytic  and  infectious 206 

physiological  extension  of. 91 

the  anatomical  distribution  of. 57 

traumatic 187 

Dropsy,  cardiac 119 

renal 142 

Dyspnoea 135 

ECLAMPSIA 86 

Emboli : 66 

lodgment  of,  predisposition  of  certain  organs 70 

Embolism 68 

—  the  consequences  of. 71 

Enchondrosis 49 

Endothelioma 51 

Epilepsy 165 

Epithelioma 52 

Eutrophia 18 

Exostosis 49 

Exudate 119 

Exudation,  inflammatory 22 

FEVER 73 

relation  of  microphytes  to 206 

Fibroma 50 

Frenzy 176 

Freezing 194 

GANGRENE m 

Gastrectasis I22 

Glandular  hypertrophies 49 

Glychsemia 143 

Gout 14« 

Granulation 29 


260  INDEX. 

HALLUCINATION 177 

Heart's  action,  (sudden  decrease  or)  failure  in 117 

Hematoma Ill 

Hemorrhage 106 

Herpes  zoster 184 

Heteroplasms,  archiplastio 52 

paraplastic 50 

HydraBinia 140 

Hypersemia,  active 16 

arterial 18 

collateral 103 

venous 104 

Hyperaesthesia 157 

Hypercinesia 161 

Hyperplasia 36 

Hypertrophy 18 

inflammatory 37,  47 

Hypnotism 167 

Hypocinesia 168 

ICTERUS 143 

gravis 150 

Idiocy 178 

Illusions 177 

Inflammation 20 

—  catarrhal 33,  201 

chronic  interstitial 36 

— croupous 34 

diphtheritic 31 

parenchymatous 30 

pus  formation 26 

special  varieties  of. 30 

—  specific 38,  215 

Infusoria 215 

Insolatio 192 

Ischsemia 102 

KIDNEYS,  derangement  in  the  function  of 138 

LEPROSY 235 

Leucaemia ...  130 


INDEX.  261 


Lipoma 
Livores  mortis 


MANIA  ...........................................................................  i78 

Marasmus  .........................................................................  126 

Melanaemia  .........................................................................  130 

Melancholia  ........................................................................  177 

Melanosis  ...........................................................................  131 

Metastasis  ...........................................................................  58 

Micrococcus  .......................................................................  224 

Migraine  ............................................................................  179 

Monstrosities  .......................................................................  238 

Motor  neuroses  ...................................................................  164 

Mould  fungi  ......................................................................  215 

Myxoma  .............................................................................  50 

NECROBIOSIS  ................................................................  94 

Necrosis  .............................................................................     93 

Nematodes  ..........................................................................  207 

Nervous  system,  irritation  of  ..................................................     84 

Neuralgia  ...........................................................................  158 

Neuro-vegetal  disturbances  ...................................................  179 

Nutrition,  defective  .............................................................  126 

-  disturbances  of  .........................................................     92 

—  local  principles  of.  ....................................................     18 

OEDEMA  ........................................................................  103 

Osteoma  ............................................................................     61 

PAIN  .......................................  :  .....................................  87 

Papilloma  ...........................................................................  49 

Paralysis  ...........................................................................  168 

-  cerebral  ...................................................................  174 

-  peripheral  ................................................................  169 

-  reflex  .......................................................................  174 

-  spinal  .......................................................................  172 

Parasites,  animal  .................................................................  206 

-  vegetable  ..................................................................  215 

Pathology,  general,  introduction  and  classification  of.  ................     16 

-  special  .....................................................................  186 


262  INDEX. 

PAGE 

Phlogosis 20 

Polypi,  mucous,  of  scalp 50 

Psoriasis  cutanea 184 

Psychical  irritation 175 

paralysis 178 

RESPIRATION,  disturbances  of. 134 

Cheyne-Stokes 137 

Rigor  mortis 94 

SARCOMA 51 

Shock 89 

Smallpox 232 

Suffocation 138 

Symptoms,  deuteropathic  groups  of. 57 

protopathic  groups  of. 13 

Syphilis 233 

TERATOMA 46 

Tetanus 89 

Thrombi,  migrating 69 

Thrombosis  in  heart  and  arteries 67 

in  veins 61 

Trauma,  chemical 189 

electrical 201 

mechanical -. 187 

thermal 192 

Trematodes 210 

Trismus 89 

Tropho-neuroses 181 

Tuberculosis 226 

Tumors,  benign  and  malignant 54 

definition  and  general  etiology  of. 40 

general  anatomy  and  nomenclature  of. 42 

heteroplastic 50 

hyperplastic 49 

ULCERATION  and  ulcer 35 

Uramia 138 

Urinary  gravel  and  calculi 147 

Urobilinuria 152 


INDEX.  263 


1'AQE 


VEGETATIVE  disturbances 91 

Verruca 49 

Vomiting 123 

YEAST  fungi 217 


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THE  T  QUIZ-COMPENDS  ?. 


Synonyms,  Definitions,  Causes,  Symptoms,  Prognosis, 
Diagnosis,  Treatment,  etc.,  of  each  disease,  and  includ- 
ing a  number  of  new  prescriptions.  They  have  been 
compiled  from  the  lectures  of  prominent  Professors,  and 
reference  has  been  made  to  the  latest  writings  of  Pro- 
fessors FLINT,  DA  COSTA,  REYNOLDS,  BARTHOLOW, 
ROBERTS  and  others. 

"  It  is  brief  and  concise,  and  at  the  same  time  possesses  an  accu- 
racy not  generally  found  in  compends." — yas.  M.  French,  M.D., 
Ass't  to  the  Prof,  of  Practice,  Medical  College  of  Ohio,  Cincinnati. 

"  The  book  seems  very  concise,  yet  very  comprehensive.    . 
An  unusually  superior  book."— Dr.  E.  T.  Bruen,  Demonstrator 
of  Clinical  Medicine,  University  of  Pennsylvania. 

"  I  have  used  it  considerably  in  connection  with  my  branches  in 
the  Quiz-class  of  the  University  of  La."— J.  H.  Bemiss,  New 
Orleans. 

"  Dr.  Hughes  has  prepared  a  very  useful  little  book,  and  I  shall 
take  pleasure  in  advising  my  class  to  use  it." — Dr.  George  IV. 
Hall,  Prof essor  of  Practice ,  St.  Louis  College  of  Physicians  and 
Surgeons. 

No.  4.    PHYSIOLOGY. 

A  Compend  of  Human  Physiology,  adapted  to  the  use 
of  Students.  By  ALBERT  P.  BRUBAKER,  M.D.,  De- 
monstrator of  Physiology  in  Jefferson  Medical  College, 
Philadelphia. 

"  Dr.  Brubaker  deserves  the  hearty  thanks  of  medical  students 
for  his  Compend  of  Physiology.  He  has  arranged  the  fundamental 
and  practical  principles  of  the  science  in  a  peculiarly  inviting  and 
accessible  manner.  I  have  already  introduced  the  work  to  my 
class."— Maurice  N.  Miller,  M.D.,  Instructor  in  Practical  His- 
tology,  former  ly  Demonstrator  of  Physiology,  University  City  of 

"  '  Quiz-Compend '  No.  4  is  fully  up  to  the  high  standard  estab- 
lished by  its  predecessors  of  the  same  series."— Medical  Bulletin, 
Philadelphia. 

"  I  can  recommend  it  as  a  valuable  aid  to  the  student." — C.  N. 
Ellin-wood,  M.D.,  Professor  of  Physiology,  Cooper  Medical  Col- 
lege, San  Francisco. 

"  This  is  a  well  written  little  book."— London  Lancet. 

No.  5.     OBSTETRICS. 
A  Compend  of  Obstetrics.   For  Physicians  and  Students. 

By  HENRY  G.  LANDIS,  M.D.,  Professor  of  Obstetrics 

and  Diseases  of  Women,  in  Starling  Medical  College, 

Columbus.     Illustrated. 

"  We  have  no  doubt  that  many  students  will  find  in  it  a  most  val- 
uable aid  in  preparing  for  examination." — The  American  "Journal 
a/ Obstetrics. 

"  It  is  complete,  accurate  and  scientific.     The  very  best  book  ol 
its  kind  1  have  seen."— J.  S.  Knox,  M.D.,  Lecturer  on  Obstetrics, 
Rush  Medical  College,  Chicago. 
Price  of  each  Book,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


THE  T  QU1Z-COMPENDS  ?. 


"  I  have  been  teaching  in  this  department  for  many  years,  and  am 
free  to  say  that  this  will  be  the  best  assistant  I  ever  had.  It  is  ac- 
curate and  comprehensive,  but  brief  and  pointed." — Prof.  P.  D. 
Yost,  St.  Louis. 

No.  6.    MATERIA  MEDIOA.    Revised  Ed. 

A  Cpmpend  on  Materia  Medica  and  Therapeutics,  with 
especial  reference  to  the  Physiological  Actions  of 
Drugs.  For  the  use  of  Medical,  Dental,  and  Pharma- 
ceutical Students  and  Practitioners.  Based  on  the  New 
Revision  (Sixth)  of  the  U.  S.  Pharmacopoeia,  and  in- 
cluding many  unofficinal  remedies.  By  SAMUEL  O. 
L.  Potter,  M.A.,  M.D.,  U.  S.  Army. 

"  I  have  examined  the  little  volume  carefully,  and  find  it  just 
such  a  book  as  I  require  in  my  private  Quiz,  and  shall  certainly  re- 
commend it  to  my  classes.  Your  Compends  are  all  popular  here  i 


Washington."— John  E.Brackett,  M.D.,  Professor  of  Materia 
Medica  and  Therapeutics,  Howard  Medical  College,  Washington. 
"  Part  of  a  series  of  small  but  valuable  text-books.  .  .  .  While 
the  work  is,  owing  to  its  therapeutic  contents,  more  useful  to  the 
medical  student,  the  pharmaceutical  student  may  derive  much  use- 
ful information  from  it." — N.  Y.  Pharmaceutical  Record. 

No.  7.    CHEMISTRY.    Revised  Ed. 

A  Compend  of  Chemistry.     By  G.  MASON  WARD,  M.D., 
Demonstrator  of  Chemistry  in  Jefferson  Medical  Col- 
lege, Philadelphia.    Including  Table  of  Elements  and 
various  Analytical  Tables. 
"  Brief,  but  excellent.  ...  It  will  doubtless  prove  an  admirable 

aid  to  the  student,  by  fixing  these  facts  in  his  memory.    It  is  worthy 

brar 


o  te  stuent,    y    xng  tese  acts  n     s  memory.      t  s  worty 
the  study  of  both  medical  and  pharmaceutical   students   in   this 
ch."—  Pharmaceutical  Record,  New  York. 


No.  8.    VISCERAL  ANATOMY. 
A  Compend  of  Visceral  Anatomy.     By  SAMUEL  O.  L. 
POTTER,  M.A.,  M.D.,  U.  S.  Army.    With  40  Illustrations. 
"V*  This  is  the  only  Compend  that  contains  full  descriptions  of  the 
viscera,  and  will,  together  with  No.  i  of  this  series,  form  the  only 
complete  Compend  of  Anatomy  published. 

No.  9.    SURGERY.    Illustrated. 

A  Compend  of  Surgery  ;  including  Fractures,  Wounds, 
Dislocations,  Sprains,  Amputations  and  other  opera- 
tions, Inflammation,  Suppuration,  Ulcers,  Syphilis, 
Tumors,  Shock,  etc.  Diseases  of  the  Spine,  Ear,  Eye, 
Bladder,  Testicles,  Anus,  and  other  Surgical  Diseases. 
By  ORVILLE  HORWITZ,  A.M.,  M.D.,  with  43  Illustra- 
tions. 
Price  of  Each,  Cloth,  $1.00.  Interleaved  for  Notes,  $1.25. 


THE  ?QUIZ-COMPENDS? 


No.  10.    ORGANIC  CHEMISTRY. 

JUST  PUBLISHED. 

A  Compend  of  Organic  Chemistry,  including  Medical 
Chemistry,  Urine  Analysis,  and  the  Analysis  of  Water, 
and  Food,  etc.  By  HENRY  LEFFMANN,  M.D.,  Pro- 
fessor of  Clinical  Chemistry  and  Hygiene  in  the  Phila- 
delphia Polyclinic ;  Professor  of  Chemistry,  Penn- 
sylvania College  of  Dental  Surgery ;  Member  of  the 
N.  Y.  Medico-Legal  Society.  Cloth.  $1.00. 

Interleaved,  for  the  addition  of  Notes,  $1.25. 

Nature  of  Organic  Bodies.  Transformations  under  various  con- 
ditions. Organic  Synthesis.  Homologous  and  Isomeric  Bodies. 
Empirical  and  Rational  formulae.  Classification  of  organic  bodies. 
Hydrocarbon.  Derivatives  of  Hydrocarbons.  Alcohols  and  Ethers. 
Benzenes  and  Turpenes.  Fat  Acids,  Oils  and  Fats,  Sugars,  Gluco- 
sides.  Cyanogen  Compounds  Amines  and  Amides.  Alkaloids. 
Ptomaines.  Animal  Chemistry.  Nutrition  and  Assimilation. 
Food,  Water  and  Air.  Urinary  Analysis.  Index. 

The  Essentials  of  Pathology. 

BY  D.  TOD  GILLIAM,  M.D., 

Professor  of  Physiology  in  Starling  Medical  College,  Columbus,  O. 
With  47  Illustrations.    12mo.    Cloth.    Price  $2.00. 

*#*  The  object  of  this  book  is  to  unfold  to  the  beginner  the  funda- 
mentals of  pathology  in  a  plain,  practical  way,  and  by  bringing  them 
within  easy  comprehension  to  increase  his  interest  in  the  study  of 
the  subject.  Though  it  will  not  altogether  supplant  larger  works, 
it  will  be  found  to  impart  clear-cut  conceptions  of  the  generally 
accepted  doctrines  of  the  day,  and  to  prevent  confusion  in  the  mind 
of  the  student. 


A  POCKET-BOOK  OF 

PHYSICAL    DIAGNOSIS 

OF  THE 

Diseases  ofihe  Heart  and  Lungs. 

A  MANUAL  FOR  STUDENTS  AND   PHYSICIANS. 
BY  DR.  EDWARD  T.  BRUEN, 

Demonstrator  of  Clinical  Medicine  in  the  University  of  Pennsyl- 
vania, Assistant  Physician  to  the  University  Hospital,  etc. 
Second  Edition,  Revised.   With  new  Illustrations.    12mo.    $1.50. 
*,*The  subject  is  treated  in  a  plain,  practical  manner,  avoiding 
questions  of  historical  or  theoretical  interest,  and  without  laying 
special  claim  to  originality  of  matter,  the  author  has  made  a  book 
that  presents  the  somewhat  difficult  points  of  Physical  Diagnosis 
clearly  and  distinctly. 


STUDENTS'  MANUALS. 


TYSON,  ON  THE  URINE.  A  Practical  Guide  to 
the  Examination  of  Urine.  For  Physicians  and  Stu- 
dents. By  JAMES  TYSON,  M.D.,  Professor  of  Path- 
ology and  Morbid  Anatomy,  University  of  Pennsylva- 
nia. With  Colored  Plates  and  Wood  Engravings. 
Fourth  Edition.  lamo,  cloth,  $1.50 

HEATH'S  MINOR  SURGERY.  A  Manual  of 
Minor  Surgery  and  Bandaging.  By  CHRISTOPHER 
HEATH,  M.D.,  Surgeon  to  University  College  Hospital, 
London.  6th  Edition.  115111.  I2mo,  cloth,  $2.00 

REESE.  A  MANUAL  OF  MEDICAL  JURIS- 
PRUDENCE and  Toxicology,  for  Students  and 
Physicians.  Small  8vo,  606  pp.  Cl.  $4.00;  Lea.  5.00 

VIRCHOW'S  POST-MORTEMS.  Post-Mortem 
Examinations.  A  Description  and  Explanation  of  the 
Methods  of  Performing  them.  By  PROF.  RUDOLPH 
VIRCHOW,  of  Berlin.  Translated  by  DR.  T.  B.  SMITH. 
2d  Ed.  4  Lithographic  Plates.  I2mo,  cloth,  £1.25 

DULLES'  ACCIDENTS  AND  EMERGEN- 
CIES. What  To  Do  First  in  Accidents  and  Emer- 
gencies. A  Manual  Explaining  the  Treatment  of 
Surgical  and  other  Accidents,  Poisoning,  etc.  By 
CHARLES  W.  DULLES,  M.D.,  Surgeon  Out-door  De- 
partment, Presbyterian  Hospital,  Philadelphia.  Col- 
ored Plate  and  other  Illustrations.  32010,  cloth,  .75 

BEALE,  ON  SLIGHT  AILMENTS.  Their  Na- 
ture and  Treatment.  By  LIONEL  S.  BEALE,  M.D., 
F.R.S.  Second  Edition.  Revised,  Enlarged  and  Illus- 
trated. 283  pages.  8vo. 

Paper  covers,  75  cents;  cloth,  $1.25 

ALLINGHAM,  ON  THE  RECTUM.  Fistula?, 
Hemorrhoids,  Painful  Ulcer,  Stricture,  Prolapsus,  and 
other  Diseases  of  the  Rectum ;  Their  Diagnosis  and 
Treatment.  By  WM.  ALLINGHAM,  M.D.  Fourth  Re- 
vised and  Enlarged  Edition.  Illustrated.  8vo. 

Paper  covers,  75  cents;  cloth,  $1.25 

THOMPSON,  ON  THE  URINARY  ORGANS. 

On  Diseases  of  the  Urinary  Organs.  By  SIR  HENRY 
THOMPSO  N,M.D.,  F.R.C.S.  Seventh  Edition.  84  Illus- 
trations. 8vo.  Paper  covers,  75  cents;  cloth,  $1.25 


STUDENTS'  MANUALS. 


MARSHALL  AND  SMITH,  ON  THE  URINE. 

The  Chemical  Analysis  of  the  Urine.  By  JOHN  MAR- 
SHALL,  M.D.,  Chemical  Laboratory,  University  of  Penn- 
sylvania, and  PROF.  E.  F.  SMITH.  Illus.  Cloth,  |i  oo 

MEARS'  PRACTICAL  SURGERY.  Surgical 
Dressings,  Bandaging,  Ligation,  Amputation,  etc.  By 
T.  EWING  MEARS,  M.D.,  Demonstrator  of  Surgery  in 
Jefferson  Med.  College.  227  Illus.  ad  Ed,  In  Press. 

HOLDEN'S  ANATOMY.  A  Manual  of  the  Dis- 
section of  the  Human  Body.  Fifth  Edition,  Revised 
and  Enlarged,  with  over  190  Illustrations.  In  Press. 

BLOXAM'S  LABORATORY  TEACHINGS. 
Progressive  Exercises  in  Practical  Chemistry.  By  PROF. 
C.  L.  BLOXAM.  89  Illustrations.  I2mo,  cloth,  $1.75 

TYSON,  ON  THE  CELL  DOCTRINE;  its  His- 
tory and  Present  State.  By  PROF.  JAMES  TYSON,  M.D, 
Second  Edition.  Illustrated.  I2mo,  cloth,  $2.00 

MEADOWS'  MIDWIFERY.  A  Manual  for  Stu- 
dents. By  ALFRED  MEADOWS,  M.D.  From  Fourth 
London  Edition.  145  Illustrations.  8vo,  cloth,  $2.00 

WYTHE'S  DOSE  AND  SYMPTOM  BOOK. 
Containing  the  Doses  and  Uses  of  all  the  principal 
Articles  of  the  Materia  Medica,  etc.  Eleventh  Edi- 
tion. 32mo,  cloth,  $1.00;  pocket-book  style,  $1.25 

PHYSICIAN'S  PRESCRIPTION  BOOK.  Con- 
taining  Lists  of  Terms,  Phrases,  Contractions  and 
Abbreviations  used  in  Prescriptions,  Explanatory  Notes, 
Grammatical  Construction  of  Prescriptions,  etc.,  etc. 
By  PROF.  JONATHAN  PEREIRA,  M.D.  Sixteenth  Edi- 
tion. 32010,  cloth,  $  I.  oo ;  pocket-book  style,  $1.25 

POCKET  LEXICONS. 

CLEAVELAND'S  POCKET  MEDICAL  LEXI- 
CON. A  Medical  Lexicon,  containing  correct  Pro- 
nunciation and  Definition  of  Terms  used  in  Medi- 
cine and  the  Collateral  Sciences.  Thirtieth  Edition. 
Very  small  pocket  size.  Red  Edges. 

Cloth,  75  cents;  pocket-book  style,  |i.oo 

LONGLEY'S  POCKET  DICTIONARY.  The 
Student's  Medical  Lexicon,  giving  Definition  and  Pro- 
nunciation of  all  Terms  used  in  Medicine,  with  an 
Appendix  giving  Poisons  and  Their  Antidotes,  Abbre- 
viations used  in  Prescriptions,  Metric  Scale  of  Doses, 
etc.  24mo,  cloth,  $1.00;  pocket-book  style,  $1.25 


ROBERTS'  PRACTICE. 

FIFTH  EDITION. 
Recommended  as  a   Text-book  at  University  of  Pennsylvania 

Long  Island  College  Hospital,  Yale  and  Harvard  Colleges, 
Bishop's  College,  Montreal,  University  of  Michigan,  and 

over  twenty  other  Medical  Schools. 
A  HANDBOOK  OF  THE  THEORY  AND  PRACTICE  OF 

MEDICINE.     By   FREDERICK   T.   ROBERTS,  M.D.,   M.R.C.P., 

Professor  of  Clinical  Medicine  and  Therapeutics  in  University 

College  Hospital,  London.     Fifth  Edition.     Octavo. 

CLOTH,  $5.00;  LEATHER,  $6.00. 

***  This  new  edition  has  been  subjected  to  a  careful  revision. 
Many  chapters  have  been  rewritten.  Important  alterations  and 
additions  have  been  made  throughout,  and  new  illustrations  intro- 
duced. 

"A  clear,  yet  concise,  scientific  and  practical  work.  It  is  a  capi- 
tal compendium  of  the  classified  knowledge  of  the  subject." — Prof. 
J.  Adams  Allen,  Rush  Medical  College,  Chicago. 

"  I  have  become  thoroughly  convinced  of  its  great  value,  and 
have  cordially  recommended  it  to  my  class  in  Yale  College." — 
Prof.  David  P.  Smith. 

"  1  have  examined  it  with  some  care,  and  think  it  a  good  book, 
and  shall  take  pleasure  in  mentioning  it  among  the  works  which 
may  properly  be  put  in  the  hands  of  students." — A.  B.  Palmer, 
Prof,  of  the  Practice  of  Medicine,  University  of  Michigan. 

"  It  is  unsurpassed  by  any  work  that  has  fallen  into  our  hands, 
as  a  compendium  for  students  preparing  for  examination.  It  is 
thoroughly  practical,  and  fully  up  to  the  times." — The  Clinic. 

"Our  opinion  of  it  is  one  of  almost  unqualified  praise.  The 
style  is  clear,  and  the  amount  of  useful  and,  indeed,  indispensable 
information  which  it  contains  is  marvelous."— Boston  Medical  and 
Surgical  Journal. 

BIDDLE'S  MATERIA  MEDICA. 

NINTH  REVISED  EDITION. 

Recommended  as  a    Text-book  at    Yale    College,    University  of 

Michigan,   College  of  Physicians  and  Surgeons,  Baltimore, 

Baltimore  Medical  College,  Louisville  Medical  College, 

and  a  number  of  other  Colleges  throughout  the  U.  S. 
BIDDLE'S  MATERIA  MEDICA.  For  the  Use  of  Students  and 
Physicians.  By  the  late  PROF.  JOHN  B.  BIDDLE,  M.D.,  Profes- 
sor of  Materia  Medica  in  Jefferson  Medical  College,  Philadelphia. 
The  Ninth  Edition,  thoroughly  revised,  and  in  many  parts  re- 
written, by  his  son,  CLEMENT  BIDDLB,  M.D.,  Past  Assistant 
Surgeon,  U.  S.  Navy,  assisted  by  HENRY  MORRIS,  M.D. 

CLOTH,  $4.00  ;  LEATHER,  $4.75. 
"  I  shall   unhesitatingly  recommend  it  (the  gth  Edition)  to  my 
students  at  the  BELLEVUE  HOSPITAL  MEDICAL  COLLEGE. — Prof. 
A.  A.  Smith,  New  York,  June,  1883. 

"  The  standard  '  Materia  Medica'  with  a  large  number  of  medi- 
cal students  is  Biddle's."— Buffalo  Medical  and  Surf  ical  Journal. 
"  The  larger  works  usually  recommended  as  text-books  in  our 
medical  schools  are  too  voluminous  for  convenient  use.     This  work 
will  be  found  to  contain  in  a  condensed  form  all  that  is  most  valuable, 
and  will  supply  students  with  a  reliable  guide." — Chicago  Med.  yi. 
***  This  Ninth  Edition  contains  all  the  additions  and  changes  in 
the  U.  S.  Pharmacopoeia,  Sixth  Revision. 


Just  Published,  September,  1884. 

VAN  HARLINGEN  ON  SKIN  DISEASES. 

A  Handbook  of  the  Diseases  of  the  Skin,  their  Di- 
agnosis and  Treatment.  By  Arthur  Van  Harlingen,  M.D., 
Professor  of  Diseases  of  the  Skin  in  the  Philadelphia 
Polyclinic,  Consulting  Physician  to  the  Dispensary  for 
Skin  Diseases,  etc.  Illustrated  by  two  colored  litho- 
graphic plates. 

12MO.    284  PAGES.    CLOTH.    PRICE,  $1.75. 

***This  is  a  complete  epitome  of  skin  disease,  arranged  in  al- 
phabetical order,  giving  the  diagnosis  and  treatment  in  a  concise, 
practical  way.  Many  prescriptions  are  given  that  have  never  been 
published  in  any  text-book,  and  an  article  incorporated  on  Diet. 
The  plates  do  not  represent  one  or  two  cases,  but  are  composed  of  a 
number  of  figures,  accurately  colored,  showing  the  appearance  of 
various  lesions,  and  will  be  found  to  give  great  aid  in  diagnosing. 

BYFORD,  DISEASES  OF  WOMEN. 

NEW  REVISED  EDITION. 

The  Practice  of  Medicine  and  Surgery,  as  applied  to  the 
Diseases  of  Women.  By  W.  H.  BYFORD,  A.M.,  M.D., 
Professor  of  Gynaecology  in  Rush  Medical  College; 
of  Obstetrics  in  the  Woman's  Medical  College ;  Sur- 
geon to  the  Woman's  Hospital;  President  of  the 
American  Gynaecological  Society,  etc.  Third  Edition. 
Revised  and  Enlarged ;  much  of  it  Rewritten ;  with 
over  1 60  Illustrations.  Octavo. 

PRICE,  CLOTH,  $5.00;  LEATHER,  $6.00. 

"  The  treatise  is  as  complete  a  one  as  the  present  state  of  our 
science  will  admit  of  being  written.  We  commend  it  to  the  diligent 
study  of  every  practitioner  and  student,  as  a  work  calculated  to  in- 
culcate sound  principles  and  lead  to  enlightened  practice  " — New 
York  Medical  Record. 

"  The  author  is  an  experienced  writer,  an  able  teacher  in  his  de- 
partment, and  has  embodied  in  the  present  work  the  results  of  a 
wide  field  of  practical  observation.  We  have  not  had  time  to  read 
its  pages  critically,  but  freely  commend  it  to  all  our  readers,  as  one 
of  the  most  valuable  practical  works  issued  from  the  American 
press."—  Chicago  Medical  Examiner. 

MACKENZIE,  THE  THROAT  AND  NOSE. 

By  MORELL  MACKENZIE,  M.D.,  Senior  Physician  to  the 

Hospital  for  Diseases  of  the  Chest  and  Throat ;  Lecturer 

on  Diseases  of  the  Throat  at  the  London  Hospital,  etc. 

VOL.  I.   Including  the  PHARYNX,  LARYNX,  TRACHEA, 

etc.     1 12  Illustrations.    Cloth, $4.00;  Leather,  $5.00 

VOL.  II.     DISEASES  OF  THE   OESOPHAGUS,  NASAL 

CAVITIES  AND  NECK.    Cloth,  $3.00;  Leather,  $4,00 

The  two  volumes  at  one  time.    Cloth,  $6.00 :  Leather,  $7.50 


49"AN  ENCYCLOPAEDIA  OP  MEDICAL  KNOWLEDGE. "Cd 

INDEX  OF  DISEASES; 

WITH  TREATMENT  AND  FORMULAE. 

By  THOS.  HAWKES  TANNER,  M.D. 

REVISED  AND  ENLARGED  BY  DR.  BROADBENT. 

Octavo,  Cloth.    Price  $3.00. 

***  The  worth  of  a.  work  of  this  kind,  by  so  eminent  a.  professor 
as  Dr.  Tanner,  cannot  be  over-estimated.  As  an  aid  to  physicians 
and  druggists,  both  in  the  country  and  city,  it  must  be  invaluable. 
It  contains  a  full  list  of  all  diseases,  arranged  in  alphabetical  order, 
with  list  of  formulae,  and  appendix  giving  points  of  interest  regard- 
ing health  resorts,  mineral  waters,  and  information  about  cooking 
and  preparing  food,  etc.,  for  the  invalid  and  convalescent.  The 
page  headings  are  so  indexed  that  the  reader  is  enabled  to  find 
at  once  the  disease  wanted  ;  its  synonyms,  classification,  varie- 
ties, description,  etc.,  with  the  course  of  treatment  recommended 
by  the  best  authorities,  and  is  referred,  by  number,  to  the  several 
prescriptions  that  have  proved  most  efficacious.  These  prescrip- 
tions are  also  arranged  so  that  they  can  be  easily  referred  to,  with 
directions  how  to  use  them,  when  to  use  them,  and  what  diseases 
they  are  generally  used  in  treating.  The  directions  for  cooking 
foods  and  preparing  poultices,  lotions,  etc.,  are  very  full.  The 
work  will  be  found  specially  useful  to  students  and  young  physicians. 

RICHTER'S  CHEMISTRY, 

A  TEXT-BOOK  of  INORGANIC  CHEMISTRY  for  STUDENTS. 
By  PROF.  VICTOR  von  RICHTER, 

University  of  Breslau, 
AUTHORIZED  TRANSLATION  FROM  THE  THIRD  GERMAN  EDITION, 

By  EDGAR  F.  SMITH,  M.A.,  Ph.D., 

Professor  of  Chemistry  in  Wittenberg  College,  Springfield,  Ohio; 

formerly  in  the  Laboratories  of  the  University  of  Pennsyl- 

vania;  Member  of  the  Chemical  Society  of  Berlin. 

12mo.  89  Wood-cuts  and  Col.  Lithographic  Plate  of  Spectra.  $2.00 

In  the  chemical  text-books  of  the  present  day,  one  of  the  striking 
features  and  difficulties  we  have  to  contend  with  is  the  separate 
presentation  of  the  theories  and  facts  of  the  science.  These  are 
usually  taught  apart,  as  if  entirely  independent  of  each  other,  and 
those  experienced  in  teaching  the  subject  know  only  too  well  the 
trouble  encountered  in  attempting  to  get  the  student  properly  in- 
terested in  the  science  and  in  bringing  him  to  a  clear  comprehension 
of  the  same.  In  this  work  of  PROF.  VON  RICHTER,  which  has  been 
received  abroad  with  such  hearty  welcome,  two  editions  having 
been  rapidly  disposed  of,  theory  and  fact  are  brought  close  together, 
and  their  intimate  relation  clearly  shown.  From  careful  observa- 
tion of  experiments  and  their  results,  the  student  is  led  to  a  correct 
understanding  of  the  interesting  principles  of  chemistry.  The  de- 
scriptions of  the  various  inorganic  substances  are  full,  and  embody 
the  results  of  the  latest  discoveries. 

In  preparation,  "ORGANIC  CHEMISTRY,'  By  the  same 
author.  Translated. 


YEO'S   PHYSIOLOGY. 

A  MANUAL  FOR  STUDENTS.    JUST  READY. 
300    CAREFULLY    PRINTED    ILLUSTRATIONS. 

FULL  GLOSSARY  AND  INDEX. 

By  GERALD  F.  YEO,  M.D.,  F.R.C.S.,  Professor  of  Physi- 
ology in  King's  College,  London.    Small  Octavo.    750 
pages.     Over  300  carefully  printed  Illustrations. 
PRICE,  CLOTH,  $4.00;  LEATHER,  $5.00. 

"  By  his  excellent  manual,  Prof.  Yeo  has  supplied  a  want  which 
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In  conclusion,  we  heartily  congratulate  Prof.  Yeo  on  his  work, 
which  we  can  recommend  to  all  those  who  wish  to  find  within  a 
moderate  compass  a  reliable  and  pleasantly  written  exposition  of 
all  the  essential  facts  of  physiology  as  the  science  now  stands." — 
The  Dublin  Journal  of  Med.  Science. 

"The  work  will  take  a  high  rank  among  the  smaller  text-books 
of  Physiology."— Pro/.  H.  P.  Bowditch,  Harvard  Med.  School, 
Boston. 

"  The  brief  examination  I  have  given  it  was  so  favorable  that  I 
placed  it  in  the  list  of  text-books  recommended  in  the  circular  of 
the  University  Medical  College."— Pro/.  Lewis  A.  Stimpson, 
M.  D. ,  37  East  33d  Street,  New  York. 

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ology."— Prof.  L.  B.  How,  Dartmouth  Med.  College,  Hanover, 


RINDFLEISCH. 

THE  ELEMENTS  OF  PATHOLOGY. 

TRANSLATED  BY  WM.  H.  MERCUR,  M.D. 
REVISED  AND   EDITED   BY  PROF.  JAS.  TYSON, 

Of  the  University  of  Pennsylvania. 
380  PAGES.  CLOTH.  PRICE  fz.oo. 
***It  is  the  object  of  Prof.  Rindfleisch  to  present  in 
this  volume  of  moderate  size  the  fundamental  principles 
of  Pathology  A  large  number  of  the  general  processes 
which  underlie  disease,  a  knowledge  of  which  is  essen- 
tial to  the  practical  physician,  are  plainly  presented. 
They  include,  among  others,  inflammation,  tumor  forma- 
tion, fever,  derangements  of  nutrition,  including  atrophy, 
derangements  of  the  movement  of  the  blood,  of  blood 
formation  and  blood  purification,  hypersesthesia,  anaesthe- 
sia, convulsions,  paralysis,  etc.  The  well-known  reputa- 
tion of  the  author,  his  thorough  familiarity  with,  and  his 
method  of  treating  the  subject,  make  this  most  recent  work 
peculiarly  useful  to  the  student,  as  well  as  to  the  prac- 
ticing physician  who  wishes  to  brush  up  his  pathology. 


STANDARD  TEXT-BOOKS. 


BLOXAM'S  CHEMISTRY.  Inorganic  and  Organic,  with  Ex- 
periments. Fifth  Edition.  Revised  and  Illustrated. 

8vo,  cloth,  13.75  ;  leather,  $4.75 

CARPENTER  ON  THE  MICROSCOPE  and  Its  Revelations. 
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Plates,  handsomely  printed.  Demi  8vo,  cloth,  $5.50 

DRUITT'S  SURGERY.  A  Manual  of  Modern  Surgery.  Elev- 
enth London  Edition.  369  Illustrations.  Demi  8vo,  cloth,  $5.00 

FLOWER,  DIAGRAMS  OF  THE  NERVES  of  the  Human 
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GALLABIN'S  MIDWIFERY.  A  Manual  for  Students.  Illus- 
trated. In  Preparation. 

GLISAN'S  MODERN  MIDWIFERY.  A  Text-book.  129, 
Illustrations.  8vo,  cloth,  $4.00;  leather,  £5.00 

HOLDEN'S  ANATOMY  and  Manual  of  Dissections  of  the 
Human  Body.  Fourth  Edition.  Illus.  New  Ed.  In  Press. 

HOLDEN'S  OSTEOLOGY.    A  Description  of  the  Bones,  with 

Colored  Delineations  of  the  Attachments  of  the  Muscles.      Sixth 

Edition.     61  Lithographic  Plates  and  many  Wood  Engravings. 

Royal  8vo,  cloth,  $6.00 

HEATH'S  PRACTICAL  ANATOMY  and  Manual  of  Dissec- 
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HEADLAND,  THE  ACTION  OF  MEDICINE  in  the  System. 
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KIRKE'S  PHYSIOLOGY.  A  Handbook  for  Students. 

Eleventh  Edition,  1884.  420  Illustrations.    Demi  8vo,  cloth,  fe.oo 

MANN'S  PSYCHOLOGICAL  MEDICINE  and  Allied  Ner- 
vous  Diseases;  including  the  Medico- Legal  Aspects  of  Insanity. 
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MACNAMARA  ON  THE  EYE.  A  Manual  for  Students  and 
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MEIGS  AND  PEPPER  ON  CHILDREN.  A  Practical  Trea- 
tise on  Diseases  of  Children.  Seventh  Edition,  Revised. 

8vo,  cloth,  $6.00  ;  leather,  $7.00 

PARKES'  PRACTICAL  HYGIENE.  Sixth  Revised  and  En- 
larged Edition.  Illustrated.  8vo,  cloth,  $3.00 

RIGBY'S  OBSTETRIC  MEMORANDA.        32mo,  cloth,  .50 

SANDERSON  &  FOSTER'S  PHYSIOLOGICAL  LABOR- 
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WILSON'S  HUMAN  ANATOMY.  General  and  Special. 
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WYTHE'S  MICROSCOPIST.  A  Manual  of  Microscopy  and 
Compend  of  the  Microscopic  Sciences.  Fourth  Edition.  252 
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ACTON,  ON  THE  REPRODUCTIVE  ORGANS.  Their 
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FENNER,  ON  VISION.  Its  Optical  Defects  and  the  Adaptation 
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FOTHERGILL,  ON  THE  HEART.  Its  Diseases  and  their 
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HARLEY  ON  THE  LIVER.  Diagnosis  and  Treatment.  Col- 
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Date  Due 


CAT.   NO.  24    161 


UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


II 


000633711     7 


R5T9e 
1881* 
Rindfleisch,  Georg  E 

The  elements  of  pathology 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 
IRVINE,  CA    92664 


